Abstract
Background
Pregnant and postpartum incarcerated women are at risk of adverse health outcomes due to pre-incarceration risks and exposures during incarceration.
Objectives
This study characterized maternal healthcare and neonatal outcomes among incarcerated pregnant women in Georgia from August 2020 to March 2025.
Design
We utilized a sequential mixed methods approach using data from a birth cohort of children exposed prenatally to incarceration in Georgia.
Methods
We analyzed qualitative data on maternal care experiences from 41 mothers and quantitative data on neonatal outcomes from caregivers of 84 children. Qualitative results informed exploratory tests of group differences for neonatal outcomes (i.e.,mode of delivery, neonatal complications, low birthweight) and breastfeeding initiation between (1) those who gave birth in the community compared to during incarceration; (2) those who were incarcerated in jail as compared to prisons.
Results
Participants described low-quality maternal healthcare, inhumane treatment, and lack of safety and comfort, and the use of practices like solitary confinement and shackling. Fisher’s exact tests were significant for differences in breastfeeding initiation between those who gave birth in the community compared to those who gave birth during incarceration (p = 0.002), but breastfeeding initiation did not differ between those who were incarcerated in jail as compared to prison. Mode of delivery, neonatal complications, and low birthweight did not significantly differ between those who gave birth in the community compared to those who gave birth during incarceration nor those who were incarcerated in jail as compared to in prisons.
Conclusions
Incarcerated pregnant and postpartum women in Georgia report low-quality maternal healthcare. Policy leaders should establish evidence-based policies for maternal healthcare within prisons and jails and consider community-based alternatives to incarceration for pregnant women.
Plain language summary
This study looked at the health care experiences of pregnant and postpartum women while they are in jail or prison in Georgia, as well as the health of their newborn babies. The research was done between August 2020 and March 2025. The study included 41 mothers who talked about their experiences with medical care during pregnancy and after birth while incarcerated. It also included data about babies born to 84 mothers who were in jail or prison while pregnant. Many women reported receiving poor-quality health care while incarcerated. They described feeling unsafe, being treated inhumanely, and sometimes being put in solitary confinement or shackled, even during pregnancy or childbirth. These practices can be very harmful for both the mother and the baby. Researchers compared the health of babies born to mothers who gave birth while incarcerated with those who gave birth in the community (not in jail or prison). They found that mothers who gave birth in the community were more likely to start breastfeeding their babies. The study highlights that pregnant and postpartum women in Georgia’s jails and prisons are not receiving the quality of care they need. Based on these findings, the authors recommend that policy makers should create better, evidence-based policies to support pregnant women in jail or prison. They also suggest that instead of putting pregnant women in jail or prison, community-based alternatives should be considered to protect the health and well-being of both mothers and their babies. In summary, the study shows that improving maternal healthcare in jails and prisons and considering alternatives to incarceration for pregnant women are important steps toward healthier outcomes for mothers and their children.
Introduction
The United States (U.S.) incarcerates more women per capita than any other country. 1 While men’s incarceration rates have declined, women’s rates continue to rise, 1 contributing to higher incarceration during pregnancy. Estimates suggest 2-4% of incarcerated women in prisons and 3% in jails are pregnant,2–4 but systematic data collection is lacking. Prisons house incarcerated people for a year or more, while jail stays are more variable and often shorter. This variability and lack of adequate record-keeping make it difficult to estimate the number of births during incarceration. In one study surveying 57% of U.S. prisons and 5% of jails, 1,040 pregnancies ended during incarceration between 2016 and 2017.3,4 A 2023 survey of state and federal prisons estimated 2% of women incarcerated in these settings were pregnant. 2
Most incarcerated women, many of whom are mothers, 5 are marginalized because of their race and socio-economic status.6,7 They report high rates of chronic illness, behavioral health issues, and trauma, increasing risk for adverse maternal and neonatal outcomes.8,9 Prisons and jails therefore house a particularly high-risk subset of pregnant women. Additionally, pregnancy, birth, and postpartum periods during incarceration may adversely affect maternal and perinatal health. 10 This impact on maternal and perinatal health may differ depending on the type of carceral facility. Prisons are more likely to have established medical care and robust policies regarding maternal health than jails. However, qualitative studies, including those investigating experiences in prison, report discrimination, stigma, stress, and grief due to incarceration during pregnancy and early separation from infants.11,12 Practices like use of restraints during maternity care or limited nutrition during pregnancy further contribute to risk.10,13–17
Few studies have evaluated carceral policies; however,15–17 a survey of 19 state prisons found most lacked adequate medical care, nutrition, or support, and routinely restrained pregnant or laboring women. 10 Research on the impact of incarceration on health is hampered by lack of data, small sample sizes, and fragmented systems. Despite these challenges, some studies link incarceration during pregnancy to maternal morbidity, pregnancy-related hypertension, low birthweight, pre-term birth, NICU admissions, and perinatal depression and anxiety.9,18–22
Research is urgently needed to assess maternal healthcare experiences during incarceration and their potential relationship with neonatal outcomes, particularly research on differences in maternity care experiences due to carceral facilities. This study uses data from the Birth Beyond Bars Study (BBB Study) in Georgia, which has one of the highest women’s incarceration rates in the U.S. 1 Using data from Georgia allowed us to obtain a relatively high sample size of women experiencing maternity care in jails and prisons and can illustrate outcomes in states with high women’s incarceration. We analyzed these data to address: 1) What are women’s experiences of maternal healthcare in Georgia prisons and jails? 2) Are key differences in the setting in which women are incarcerated during pregnancy and whether women give birth during incarceration associated with adverse neonatal health outcomes or breastfeeding initiation? We hypothesized that women would experience suboptimal maternity care and exposure to harmful practices and stressful environments. We further hypothesized that at least one difference in the setting in which women experienced pregnancy or birth would be associated with an adverse neonatal health outcome or breastfeeding initiation. The BBB Study is uniquely suited to these research questions as it includes a relatively robust sample size, both qualitative data on maternal care experiences and quantitative surveys of neonatal outcomes, and data from a variety of carceral experiences.
Methods
Sample
The BBB Study began enrolling children, their primary caregivers, and their formerly incarcerated mothers in August 2020. Enrollment is ongoing. For the current study, we included intake interviews conducted between August 2020 and March 2025. Although the BBB Study includes eligible children in Georgia, Pennsylvania, and Maine, only participants in Georgia were included in the current study as this site has the most robust enrollment to date. Indeed, Georgia is a high-incarcerating state, with a women’s incarceration rate of 152 per 100,000 in 2022 compared to 49 per 100,000 nationally. 23 Sampling in Georgia was undertaken in collaboration with Motherhood Beyond Bars (MBB), a nonprofit organization serving incarcerated pregnant and postpartum women and their families in Georgia. MBB staff recruited primary caregivers of infants exposed prenatally to maternal incarceration as close to the birth of the child as possible (see Supplement for recruitment details). If infants’ were cared for by their mothers at enrollment, mothers were enrolled and interviewed on infant intake. In the event of continued maternal incarceration, non-maternal primary caregivers were enrolled alongside the infant and interviewed on intake. If the mother was released during the study period (first 36 months of the infant’s life) she was also approached for enrollment and completed an intake interview if enrolled. Children were enrolled as close to their birth as possible and followed until they turned 36 months.
During the study period, we approached the primary caregivers of 131 eligible infants exposed prenatally to incarceration through their primary caregivers. Eighty four of the caregivers of the 131 infants approached were enrolled in the study. Of these, 20 were the infants’ formerly incarcerated biological mother and 64 were non-maternal caregivers. Over the course of follow-up an additional 21 biological mothers with infants under the care of enrolled non-maternal caregivers were released from incarceration and subsequently enrolled in the study. All interviewed mothers experienced pregnancy while incarcerated.
Data collection
Data for this study were drawn from intake interviews in the BBB Study (see Supplement for relevant items in interview guides). At intake, infants’ primary caregivers (whether mothers or non-maternal caregivers) completed a guided interview capturing infant and caregiver demographics and birth outcomes (gestational age, birthweight, mode of delivery, and any complications or NICU admission). If mothers of infants cared for by enrolled non-maternal caregivers were released from incarceration, they were also recruited and completed a guided interview including a semi-structured qualitative section on pregnancy, birth, and postpartum experiences and a quantitative survey. We developed questions for interviews through a literature review and discussion with formerly incarcerated mothers and staff at MBB (see Tables S1 and S2). Quantitative questions in the interview captured mothers’ and infants’ demographics, infants’ birth outcomes, breastfeeding initiation, the type (prison or jail) of the facility in which the mother was incarcerated during pregnancy and/or the postpartum period, and, if the mother remained incarcerated after the birth of the infant, the length of time in hours the mother was allowed to stay with the infant before they were separated and the age of the infant at the mother’s release. Interviews were not validated but were pilot tested with nine participants (approximately 22% of the sample). MBB staff or BK conducted all interviews. All interviewers were trained in qualitative interviewing techniques prior to data collection by BK. BK was a doctoral student in public health at the time interviews were conducted. She has significant experience in qualitative research. All interviewers were women. Two of four staff interviewers at MBB have lived experience of incarceration and motherhood. Data from the interviews were recorded and managed using REDCap and Qualtrics software. Participants were compensated $25 for completing interviews. All interviews were conducted over phone or Zoom in a location of the participant’s choice. Interviews were audio recorded and transcribed verbatim. Interviews were private on the end of the data collector, but others may have been present on the end of the participant. Interviews were approximately an hour in length. Interviews with mothers released after the birth of the infant were conducted between three weeks and 31 months post-birth, on average approximately 9 months post-birth.
Analyses
We analyzed data from 84 infants and 41 formerly incarcerated mothers using a sequential mixed-methods approach, first analyzing qualitative data to determine which quantitative analyses would further contribute to our understanding of the unique experience of pregnancy, birth, and the postpartum period during incarceration and then analyzing quantitative data. First, we analyzed 41 semi-structured interviews to characterize mothers’ experiences of prenatal, childbirth, and postpartum care during incarceration and after release. We used a modified thematic analysis approach as described by Braun & Clarke to analyze semi-structured interviews. 24 The analysis team (AH, HM, RS, MO, led by BK) developed a codebook based on a review of the literature on maternal healthcare in carceral facilities. Two members of the analysis team independently coded each transcript and resolved any differences in coding through discussion. We defined data saturation as saturation of meaning as proposed by Hennink et al. 25 As data collection was ongoing during analysis, researchers included interviews in analysis until no new topics were identified during interviewing. After coding was complete, the analysis team grouped text excerpts into each code and two members conducted a deep reading of all extracted excerpts to characterize experiences. Finally, the analysis team presented preliminary findings to seven staff members at MBB, including two members with lived experience of birth during incarceration. Staff were asked to discuss whether findings fit with their programmatic or lived experience. A recording of staff feedback was transcribed and then inductively read and discussed by the team to identify any potential nuance or differences from preliminary findings. Where these nuances or differences existed, they were incorporated into descriptions of preliminary findings.
The analysis team then discussed qualitative findings to determine potential quantitative analyses. The team determined that in addition to qualitative themes, descriptive statistics of key maternal and perinatal health outcomes would increase understanding of healthcare experiences. In addition, the team identified two key contrasts in participant experiences that could be tested quantitatively. Qualitative descriptions differed significantly depending on whether the participant was incarcerated in jail or prison during pregnancy and whether the participant gave birth during incarceration or in the community after they were released. Based on these contrasts and the data available, the team decided to undertake the following quantitative analyses.
We calculated descriptive statistics for child demographics (race, ethnicity, sex) and neonatal outcomes (gestational age, birthweight, mode of delivery, birth complications—including jaundice, resuscitation, respiratory distress, neonatal abstinence syndrome, sepsis, anemia, birth defects, hypoglycemia, hypothermia, or other—and NICU admissions) for all 84 children. For 41 mothers, we calculated statistics for demographics, carceral facility type (jail or prison), release timing, age of child at mother’s release (if applicable), breastfeeding, and time spent with the infant before separation. Finally, we undertook an exploratory analysis using Fisher’s exact and Welch’s t-tests to assess group differences between birth setting (during incarceration vs. in the community) and type of facility (jail vs. prison) with neonatal outcomes. Twins were removed from analyses of birthweight.
We followed STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) and COnsolidated criteria for REporting Qualitative research (COREQ) guidelines.
Results
Participants
Mothers (n =41) were on average 31.9 years old on enrollment. Approximately half (21, 51.2%) identified as Black. One (2.4%) mother identified as Hispanic. Twenty-three (56%) mothers gave birth during their incarceration. Most mothers in our sample experienced their incarceration during pregnancy in prison (29, 70.7%).
Maternal and infant demographics.
Qualitative experiences of maternity care
All participant names presented below are pseudonyms.
Prenatal care
Jail
Experiences of prenatal care during incarceration were highly varied according to the type and location of the facility in which participants were held.
Twelve participants experienced prenatal care in jails, representing stays in eleven different county jails. Participants reported a variety of experiences of prenatal care, ranging from “ok” to extremely traumatic. Participants (6) who reported that their prenatal care in jail was satisfactory usually did so in comparison to the little to no prenatal care they received before their incarceration. Melissa said: “They were pretty good. I saw a doctor as soon as I got there. I think I went to two doctors’ appointments outside while I was there. I mean, honestly, I’ve never gone to the doctor when I was pregnant before. They were doing better than what I was doing.”
Three participants, including Melissa, specifically expressed relief at being incarcerated during their pregnancies, as this removed them from lifestyles they felt could have harmed the pregnancy, such as substance use. Michelle stated that her stay in jail allowed her to: “be in a safe environment…and to slow down and just be able to let my baby grow and be healthy without stress and different things.”
Eight participants described negative experiences with prenatal care. These experiences ranged from delays and lack of follow-up with medications, appointments, or further testing, to experiences of extreme neglect leading directly to pregnancy complications. Participants experiencing higher-risk pregnancies reported that jails were ill-equipped to care for them. Jails frequently failed to schedule or complete high-risk testing or appointments (reported by Tanya, Shay and Tracy) or rushed to transfer or release women with high-risk pregnancies (reported by Natasha, Ashe, and Amanda). Natasha said: “Because I had HIV, I had to go to a special hospital…when I was going to other counties (jails), they wasn’t trying to…take me to where I needed to go. So, I wasn’t really getting my appointments…They didn’t spend money out of their pocket to take me to [the hospital].”
She was later released early to pursue her own care.
Ashe and Crystal, who experienced incarceration in the same jail, reported experiences of neglect they felt led to health complications. Crystal was booked into jail during her early pregnancy. She disclosed that her pregnancy was the result of sexual assault to a jail administrator. Despite assuring the jail administrator that she was not a risk to herself and had not contemplated self-harm, the jail administrator flagged her as a suicide risk. Crystal was put naked into an isolation cell for observation. She reported that the cell didn’t have access to water or toilet paper. She was left there for over 48 hours. During that time, she became severely dehydrated and had to be transferred to the hospital for IV rehydration.
Ashe experienced a high-risk twin pregnancy with a history of preterm delivery and gestational hypertension during her incarceration. After reporting worrying symptoms, she was transferred to a local hospital, where she was diagnosed with sepsis and prescribed antibiotics. On her return to jail, the healthcare staff refused to give her the prescribed antibiotics. Several days later she experienced symptoms of infection so severe that she was transferred to the hospital. Her sepsis had progressed so far that her twins had to be delivered via an emergency C-section at 28 weeks. Both were extremely medically fragile, but one contracted sepsis in utero and spent several months in the NICU.
Prison
Twenty-nine participants experienced prenatal care in prison. In the Georgia Department of Corrections (GDC), pregnant women are held at a medical facility during pregnancy. While experiences of prenatal care were also highly varied, participants incarcerated in prison reported, on average, more positive experiences. Seven mothers said that they felt they received high quality prenatal care. They reported high satisfaction with the visiting obstetrician, felt their concerns were taken seriously, and that medications and follow-up care were handled appropriately. Participants reported that being housed in a medical facility was appreciated, compared to being in general population in another carceral facility. Heather said: “I felt like it was good…because there were only a few of us there. If I would’ve been in a big prison with a bunch of people, trying to see medical is so hard…but at [facility]…if we needed to see a doctor, he made it a point to see us.”
In contrast, ten mothers reported low satisfaction with their prenatal care. These participants reported not being taken seriously when they brought up symptoms; delays in routine testing, such as glucose testing, ultrasounds, and testing for infectious diseases; delayed medications; and difficulty receiving follow-up care outside of the facility. Participants frequently reported being told to “go lie down” as a response to any worrying symptom. In a typical narrative, Rachel shared: “’Cuz I remember one time…I didn’t feel my baby kick for a while, and it scared me. But they didn’t take me seriously.” Mothers who were not satisfied with their care were more likely to have high-risk pregnancies, including pregnancies with advanced maternal age, or to be young, first-time mothers.
Seventeen participants were released from prison or jail before giving birth. These participants reported problems receiving prenatal care in the community. Jalisa and Nia reported foregoing prenatal care due to problems with insurance coverage, choosing to go through their local Emergency Room for labor and birth. Tanya tried to re-establish care with her previous prenatal care provider but was turned away several times before she could be seen. While the experience of being released from prison before birth was rare, Cynthia was able to continue care with the prison’s obstetrician after explaining she would have difficulty establishing care in the community in late pregnancy.
Prenatal nutrition
Narratives of prenatal nutrition did not vary between those who were pregnant while incarcerated in jail as opposed to prison. While most participants in prison or jail reported getting some extra food during their pregnancy, several reported feeling hungry due to delays in receiving supplemental food or the insufficiency of supplemental food. All participants described food as having low nutritional value. Reported supplemental food was extra milk, a piece of white bread with cheese on it, or a piece of fruit. Candace said: “The food sucks. It’s normal prison food…it’s no different. They say it’s supposed to be different…it’s supposed to be more nutritional. The only thing that I seen was different was we got more fruit.”
Participants reported worrying that the nutrition they received was not adequate for their pregnancies to develop sufficiently. Lauren said: “A milk does not make up for the nutrition that you need when you’re carrying another human.”
Labor and birth
Twenty-four participants experienced labor and birth during their incarceration. Those that were incarcerated during labor and birth shared similar narratives whether they were incarcerated in prison or in jail. Few participants went into labor in prison or jail, as scheduled C-sections or inductions were a common experience. Those who experienced labor in a carceral facility reported not being believed that they were in labor until their water broke or they experienced bleeding. Kimberly was told by the nurses that they preferred to wait until her water broke to transfer to the hospital. Elizabeth was bleeding but was not taken seriously until her contractions were very close together. She arrived at the hospital eight centimeters dilated. Lauren reported: “When I was having contractions for several days the nurses didn’t believe me. They were telling me I’m not having contractions, and I know I’m having contractions; it was my second child.”
Once at the delivery hospital, almost all participants reported feeling well-cared for by hospital staff during labor and birth. However, they experienced significant trauma due to not being able to have a support person present during birth. Destiny remembered: “My mom and I are really, really, really close and it was just so hard being in labor without anybody being around, especially my mom. So, I was just so sad, so, so, so sad…When they told me they had to cut me, I really freaked out to the point they had to put me to sleep ‘cuz I couldn’t take it. It was too much for me, emotionally and mentally.”
Anaya described her labor: “It was just so much pain. It was very scary. It was very scary. I found myself reaching out for someone to hold my hand, but no one was there.”
Ashe said: “There were times during my C-section where I just kept thinking, I hope I don’t die on this table, because it’s a reality with women giving birth. You just don’t know. And to have to do that without your husband…without your mom, without anyone there…”
In the absence of support people during labor and birth, several participants reported turning to or wanting to turn to correctional officers in the room with them for support. Two participants (Shantae and Tara) reported they had doulas as support people during their deliveries as part of a prison-based program. They reported high satisfaction with their doulas. It is unclear why so few women had access to this program.
Women who gave birth in the community had similar experiences of scheduled or emergency C-sections, inductions, and difficult labors, but expressed joy knowing they would be with loved ones. Jalisa described her relief: “I had prayed and prayed and prayed, asked God to please release me before I had my baby…I really wanted my baby father to be there, because we're together and we're good. And he just wanted to be there as well. I did not want to have my baby alone, definitely didn't want to have to have an officer right there or whatever while I have my baby…I wanted to be with my family.”
Postpartum care
Most participants were satisfied with postpartum medical care during their hospital stay. All women who remained incarcerated postpartum experienced care in prison, including one participant who was transferred to the prison from a local jail to receive care. Prison policy typically allowed a 24-hour hospital stay in the event of a vaginal delivery and a 48-hour stay if their child was delivered by C-section, unless there were postpartum complications. At the end of their stay, women would be transferred to another prison and their newborn would remain at the hospital until a caregiver picked them up. Participants who remained incarcerated postpartum were primarily concerned with maximizing their time with their newborns before they were separated. Several policy changes occurred during the study period (2020-2025) that led to variations in postpartum experiences in the hospital and at prison facilities. These policy changes were described by participants during semi-structured interviews. Prior to November 2022, women incarcerated in prison delivered at a birthing hospital in Atlanta, where the GDC maintained a special locked unit of the hospital for incarcerated patients. Between August 2020 and late 2022, postpartum women were separated from their newborns between 45 minutes and two hours after delivery. Postpartum women were sent to the locked unit, and their infants were cared for in the NICU. Mothers who experienced this policy reported significant trauma from both early separation and their time on the locked unit. Lauren described her experience: “When I got to the prison floor…I didn’t get to take a shower the whole time I was there. When it was time to leave, they were like you need to clean yourself up and stop crying because we can’t let you leave crying like that. When I got to the transportation van, they took my pictures of my daughter away. After literally having her snatched from me they took the only thing I have left of her from me.”
This policy ended when the birthing hospital was closed in late 2022. After this closure, women delivered at a different hospital, where they were allowed to room in with their newborn unless their newborn required medical care in the NICU. Mothers who were given the opportunity to room in reported spending their time attempting to bond as much as possible with their newborn. Mothers who had postpartum complications requiring extended stays in the hospital received more time with their newborns. Destiny, who was able to room in for seven days due to postpartum complications reported: “I wouldn’t even let him sleep. Every time he tried to close his eyes; I’d wake him up and talk to him so he would know my voice.”
Regardless of the amount of time spent before separation, all mothers reported separation from their infants as an incredibly traumatic experience. Anaya said: “If I had a worse enemy, I wouldn’t wish it on anybody, that pain. To have to realize that you have to leave your newborn baby.” Amber, Stephanie, Destiny, and Angela shared that being separated brought up feelings of fear because they could no longer ensure that their newborns were safe. Participants frequently linked long-term mental health challenges to this early separation. Tara described these: “I don't even know how to describe that pain because I ain't never had to go through nothing like that because I have two other kids. And that pain right there alone does something to you. You just don't never get over that pain. Even though I'm home with her now, just thinking back, just spending that little bit of time with your child and being ripped away from your baby to go back to prison, and you sitting and looking crazy and not knowing, it's just not enough time.”
Mothers whose babies required a NICU stay (11) had to rely on correctional officers to take them to visit their children. Some received very few visits because of correctional officer understaffing. Two participants (Elizabeth and Ashe) reported being denied visits completely. To ensure they could have as many visits as possible, participants described rushing through their own postpartum care so they could see their child. Angela said: “They told me that I couldn't go to the NICU to see her until I had peed three times without the catheter in, the IV was out, and I was able to walk on my own. So as soon as the epidural wore off, I made myself stand up and just start pacing the room, to be able to walk or whatever. And then [I] was just making myself go to the bathroom without the cath…Then they took the IV out, and they let me go see her for—it was like an hour and a half, or an hour.”
Once released from the birthing hospital, mothers were transported to a large women’s prison. Until 2022, mothers were kept in the medical wing of this prison briefly and then released to general population. Mothers reported receiving very little postpartum care, even when they experienced complications. Heather described her lack of postpartum care: “They just cleaned my C-section area and gave me ibuprofen…But after I left from out of the clinic, my C-section, where they cut me tore open when I was on the compound and medical didn’t do anything for me at all…When I finally did see medical, they said, ‘Well, it just has to heal from the inside out. We’re not gonna pack it or anything.’ And they gave me some Hibiclens. And there I was like in dirty [prison] with a C-section wound open.”
Since 2022, the GDC began keeping postpartum women in a separate unit in the infirmary for six weeks after delivery. While participants reported that they had better access to medical care, this policy also included being locked down inside a cell for 72 hours followed by lock-down in a small dorm, with very limited access to outdoor time. Tina described her stay in this unit: “We never got to leave it. It sucked. It was horrible. It's like you're in a cell floor with pretty floral beds, comforters. We wanted to go outside. They would not let us go outside…They kept us locked in there.”
Dehumanization, discrimination and deprivation
In addition to experiences of maternity care, participants shared what it was like to be pregnant, give birth, and/or be postpartum and incarcerated more generally. These experiences were largely ones of dehumanization and deprivation. One particularly difficult experience was being deprived of the right to basic comfort and cleanliness. Participants described squalid cells or common areas, lack of clean water, uncomfortable beds, and lack of access to showers or hygiene products, particularly postpartum. Kira discussed the thin mattresses in the prison’s medical facility: I was hurting so bad I could barely walk. I think it's from me sleeping on that mat. We used to fight about the mats and they would [only] give you a mat to sleep on, one little small mat…I suffered my whole time.
Amanda recalled the physical conditions of the jail she was incarcerated in, where the only source of drinking water was frequently used by other incarcerated people to wash their hands: “It is so nasty and it’s like falling apart in that building. [There’s] mold in there, black mold.” Postpartum conditions for women transferred to prison were particularly unsanitary. Lauren shared: “I was in the infirmary for a few days and then they sent me down to diagnostics where I didn't get any sheets or blankets for my bed, so I had to sleep on a rubber mat for several days. I didn't get a full uniform like everybody else got, they just threw me a few things out of intake that they grabbed and sent me down to diagnostics. I was supposed to be on the bottom bunk, the girl that was in my bunk bed wouldn't get out of it. I wasn't about to fight her because, I mean, she was there on some pretty horrific charges. So I was like you can have that. It was very unsanitary. We didn't get soap and stuff like that. They barely want to give you pads when you just had a baby and you're bleeding all the time.”
Participants incarcerated held in general population in jail described feeling a lack of basic safety which caused significant stress. Nia said: “People are constantly loud. People are actually threatening in there. And so, when people see you and you're pregnant, they kind look at you as somebody who has hope. Like, oh, because you have a baby, they're going to let you go as opposed to whatever, they're sitting in there for. So, they kind of attack that.”
Participants also described being denied basic medical privacy and information about their newborns. These experiences primarily occurred in the birthing hospital, where carceral policy required a correctional officer to be present. Stephanie shared: “I mean having a baby is pretty private and personal…There was a couple of times where I wished that they [correctional officers] weren’t in a certain position, couldn’t see something, or couldn’t hear something concerning my medical status or the baby’s…She [the correctional officer] was at the end of my bed when I delivered. I was knees to ears, and she was at the end just…watching.”
Similarly, Rachel reported not initiating breastfeeding postpartum because she didn’t want the correctional officer to see. In two instances, mothers (Elizabeth and Jaclyn) reported that medical staff denied them information about their newborns’ medical status or care because they were incarcerated.
Participants also described facing discrimination, stigma, inhumane treatment, and dangerous practices from correctional officers and other prison staff. Nearly all participants described being treated dismissively by carceral staff. Nala summarized this experience: “They treated me just like a person they don’t understand, a person that’s struggled. They knew I was pregnant, but they really didn’t care that much.” Ashe, when seeking care for her complicated twin pregnancy, was told by the jail’s medical staff, “If you’re that worried about your babies, you shouldn’t have come to jail.” In addition to this general lack of care several participants reported being subjected to dangerous or inhumane practices during their incarcerations. Jaclyn was shackled during transfer to the hospital, labor, and delivery. She reported knowing that current GDC policy prohibits shackling during labor, but no one told her why she was shackled regardless of this policy. Stephanie was forced to do a cough and squat strip search during the postpartum period, a practice that is also currently against GDC policies. Shay and Crystal reported being placed in solitary confinement during their pregnancies. Both Shay and Crystal were incarcerated in county jails. Shay was placed in lockdown following a positive pregnancy test, and Crystal for suicide watch as described above. One participant, Rachel, reported that she felt medical staff and correctional officers at the prison medical facility discriminated against her because she was white: “I felt like [sigh] that even the officers and the nurses that [because] I wasn’t African American, you know, that I wasn’t really important or any—they weren’t listenin’ to me.”
Neonatal outcomes
Neonatal outcomes.a
aNeonatal outcomes report on the sample of children (including two sets of twins). Note there is overlap between the two main comparisons (type of facility during incarceration (prison vs. jail, n = 41, from maternal report) and b1irth location (during incarceration vs. in the community, n = 84 from maternal and caregiver report)). One child is missing mode of delivery, four children are missing data on gestational age at birth, three children were missing data on birthweight, one child was missing data on NICU admission.
bOther conditions reported included failed newborn hearing screening (2), sickle cell anemia (1), hernia (1), known exposure to substances of dependence (1), “air bubbles” (1), and a broken arm (1).
Group differences between carceral experiences and birth outcomes.
1. Newborn complications-any diagnosis at birth (jaundice, birth defects, etc.).
2. Twins excluded for this analysis.
Discussion
This study adds to the wider literature on experiences of incarceration by documenting lived experiences of pregnancy, birth and the postpartum period during incarceration in Georgia. Our findings, particularly qualitative findings, highlight a lack of comprehensive maternity care and a variety of stressful and dehumanizing experiences. Our qualitative findings corroborate those from other U.S. carceral settings that separation from children and lack of emotional support are particularly traumatic and that mothers were routinely denied bodily autonomy.26,27 A strength of this study is the inclusion of narratives from participants who were released before birth and those who were not. This inclusion allowed mothers to reflect on both the overwhelming joy they felt to not face separation from their infant and the difficulty they faced securing quality maternity care post-incarceration. In addition, the inclusion of participants that experienced pregnancy in jail as well as prison illuminated frequent lapses in quality prenatal care in jails compared to prison. High variation in experiences of care in jails compared to in prisons may also reflect a lack of formalized maternal healthcare in jails. Indeed, participants incarcerated in prison articulated several maternity care policies that were shared across participants, while participants incarcerated in jails, even in the same jails, were either unaware of jail policies regarding maternity care or these did not exist.
Multiple studies have found associations between pregnancy during incarceration and adverse maternal and infant outcomes.9,19,20,28 As our study lacked a community control group, we were unable to replicate these findings. However, our findings differed substantially from state averages for births via C-section (35.2% in Georgia, 41.7% in our sample) and NICU admissions (9.8% vs. 23.8%). 29 Similarly, only 16% of women who gave birth during incarceration initiated breastfeeding, compared to 56% of Georgia mothers enrolled in the Special Supplemental Nutrition Program for Women, Infants and Children, a social service for low-income pregnant and breastfeeding women and their children under the age of five. 30 Notably, the same percentage (56%) of mothers in our sample delivering in the community initiated breastfeeding. Indeed, our comparison between women who gave birth during incarceration and those who gave birth in the community found that birth during incarceration deprived mothers and newborns of the benefits of early breastfeeding initiation. 31
While qualitative narratives highlighted variability in maternal care, particularly between birth in the community as opposed to birth in incarceration and experiencing pregnancy in jail as opposed to prison, most tests for group differences did not reach statistical significance—possibly due to limited power or the shared high baseline risk for adverse outcomes among women entering incarceration.
Limitations
Instruments used in this study were not validated, however, we pilot tested instruments with nine participants at the beginning of the study and no changes were necessary to questions included in this study. Our exploratory analyses testing potential group differences illuminated by qualitative themes were limited by the lack of a-priori power and sample size calculations as well as overall limited sample size, particularly for comparisons of exposure during pregnancy to jails as opposed to prisons (n = 41). Future research should prioritize larger samples and the inclusion of a community comparison group with similar pre-incarceration risk factors for adverse neonatal outcomes and breastfeeding initiation to aid in isolating the consequences of incarceration on outcomes.
Policy and practice implications
Our findings suggest Georgia prisons and jails do not support optimal health for pregnant or postpartum women. Jails, especially, are poorly equipped for maternal care, particularly for high-risk pregnancies. The American College of Obstetricians and Gynecologists (ACOG) and the Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) call for adequate access to high-quality and respectful prenatal care and nutrition, opportunities for postpartum bonding and breastfeeding, and the limitation of restraints during pregnancy, birth, and the postpartum period for incarcerated people.32,33 Our qualitative findings show that optimal care for this population is infrequently provided in Georgia. As our qualitative results highlight, although the GDC policies regarding maternity care have shifted over time, healthcare practices surrounding pregnancy, childbirth, and the postpartum period remain inadequate. We propose policy changes: GDC and jails should develop evidence-based policies for maternal healthcare, train staff, and communicate policies to women, following standards from ACOG and AWHONN as well as the National Commission on Correctional Healthcare. 34 In addition, Georgia law prohibits the use of restraints and solitary confinement for pregnant, birthing, and postpartum incarcerated people except in extreme circumstances. 35 Staff, including nursing staff at carceral institutions and birthing hospitals should be trained in current legislation. For women being released, re-entry counseling and warm hand-offs to prenatal care should prevent early termination of care. Ideally, these warm hand-offs should be facilitated by healthcare staff at the carceral facility. Correctional officers should not be stationed in hospital rooms. Incarcerated women should receive options counseling about the benefits of early breastfeeding, and staff should support initiation when desired. Facilities must ensure access to clean water, nutritious food, outdoor time, appropriate clothing and hygiene, bottom bunks, and work detail excuses. Policy enforcement mechanisms and safe recourse for reporting staff failures are essential.
Most importantly, Georgia should invest in policy solutions that promote community-based alternatives to incarceration for pregnant and postpartum women, especially in jails. Any such alternatives must facilitate high-quality, community-based maternal care to ensure optimal health outcomes for this marginalized population.
Supplemental material
Supplemental material - “I wouldn’t wish that on anybody, that pain”: Maternal healthcare and neonatal outcomes among women experiencing incarceration during pregnancy in Georgia
Supplemental material for “I wouldn’t wish that on anybody, that pain”: Maternal healthcare and neonatal outcomes among women experiencing incarceration during pregnancy in Georgia by Bethany Kotlar, Anissa Hernandez, Haley Morgan, Modupeola Odegbami, Renee Senior, Joanna Boyles, Vanessa Garrett, Tara Gazzuolo, Julie Poehlmann, Rebecca J. Shlafer, Henning Tiemeier and Natalie Slopen in Women’s Health.
Supplemental material
Supplemental material - “I wouldn’t wish that on anybody, that pain”: Maternal healthcare and neonatal outcomes among women experiencing incarceration during pregnancy in Georgia
Supplemental material for “I wouldn’t wish that on anybody, that pain”: Maternal healthcare and neonatal outcomes among women experiencing incarceration during pregnancy in Georgia by Bethany Kotlar, Anissa Hernandez, Haley Morgan, Modupeola Odegbami, Renee Senior, Joanna Boyles, Vanessa Garrett, Tara Gazzuolo, Julie Poehlmann, Rebecca J. Shlafer, Henning Tiemeier and Natalie Slopen in Women’s Health.
Supplemental material
Supplemental material - “I wouldn’t wish that on anybody, that pain”: Maternal healthcare and neonatal outcomes among women experiencing incarceration during pregnancy in Georgia
Supplemental material for “I wouldn’t wish that on anybody, that pain”: Maternal healthcare and neonatal outcomes among women experiencing incarceration during pregnancy in Georgia by Bethany Kotlar, Anissa Hernandez, Haley Morgan, Modupeola Odegbami, Renee Senior, Joanna Boyles, Vanessa Garrett, Tara Gazzuolo, Julie Poehlmann, Rebecca J. Shlafer, Henning Tiemeier and Natalie Slopen in Women’s Health.
Supplemental material
Supplemental material - “I wouldn’t wish that on anybody, that pain”: Maternal healthcare and neonatal outcomes among women experiencing incarceration during pregnancy in Georgia
Supplemental material for “I wouldn’t wish that on anybody, that pain”: Maternal healthcare and neonatal outcomes among women experiencing incarceration during pregnancy in Georgia by Bethany Kotlar, Anissa Hernandez, Haley Morgan, Modupeola Odegbami, Renee Senior, Joanna Boyles, Vanessa Garrett, Tara Gazzuolo, Julie Poehlmann, Rebecca J. Shlafer, Henning Tiemeier and Natalie Slopen in Women’s Health.
Footnotes
Acknowledgements
The authors would like to acknowledge the contributions of staff and leadership at Motherhood Beyond Bars. Their partnership was essential in this research. We would also like to acknowledge Anum Hussaini for her contributions to the early conceptualization of this study.
Ethical considerations
The BBB Study is covered under Harvard Longwood Area’s Institutional Review Board (IRB20-1215, 21-1247, Birth Beyond Bars). MBB staff received training on the conduct of ethical research and informed consent procedures prior to data collection.
Consent to participate
Consent for publication
Participants gave consent for publication of findings under both IRB protocols.
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This project was partially funded by the HRSA Center of Excellence in MCH grant, T03MC07648-12-06. Bethany Kotlar’s work on this project was funded by the CVD Epidemiology Training Program in Behavior, the Environment and Global Health, T32 HL098048 and the National Institute of Child Health and Development, F32 HD117535.
Declaration of conflicting interests
The authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: BK served in an unpaid capacity as a board member of Motherhood Beyond Bars from 2020 until 2023. VG, TG, and JB hold paid staff positions at Motherhood Beyond Bars.
Data Availability Statement
Due to the risk of identification of participants, the data that has been used is confidential. Interview guides are included as a supplement.
Supplemental material
Supplemental material for this article is available online.
References
Supplementary Material
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