A Mother Behind Bars

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“I was laid there on my bed, in my cell with a male nurse and a female nurse, not midwifery trained and then out popped [baby] at twenty past one. Still no ambulance, still no paramedics and she came out foot first.” 1

Pregnant and postpartum women in prisons experience greater challenges compared to other women in the prison 1. Imagine, how vulnerable a woman would feel in a prison which was originally designed for men, housing predominantly male staff, lack of antenatal care, poor social support, unaddressed parenting concerns, inadequate amenities of daily sustenance such as maternity wear, sanitary napkins, etc. leading to an unimaginable physical and psychological distress as she copes with the changes her body and mind are going through as her pregnancy progresses 2,3,4.

On the other hand, several recent studies have highlighted how the outcomes of pregnancy in prison may be better in comparison to the women belonging to a similar social background in the community, due to factors such as forced sobriety, adequate nutrition, absence of poverty, absence of homelessness, lower partner violence and regular prenatal care 5,6.

Therefore, incarcerated women present to us a unique opportunity to improve their well-being that is subject to various prison-related factors and facilities.

Worldwide, close to 7 lakh women are incarcerated, accounting for around 9% of the incarcerated population 7. Most of these women are in their reproductive age group. Few studies have reported that around 6-10% of the total women entering prisons are pregnant 8. It has also been observed that the incarceration of women is increasing at a rate that is 50% greater than men since 1980 worldwide 8.

The proportion of women entering Indian prisons has increased from 3.3% in 2000 to 4.2% in 2019 9. The largest repository of information related to prisons in India, the National Crime Records Bureau has reported that 19,913 female prisoners were in Indian jails as of December 2019 out of which only 18.3% were lodged in jails specific to women 9. Also, a total of 1,543 women were living with their children inside the prison 9.

No Indian data could be found looking at the prevalence of pregnant women inside prisons. Unfortunately, most correctional settings are not mandated to track or report pregnancy-related data and do not routinely screen for pregnancy 4.

It is crucial to emphasize the importance of perinatal mental health in prisons. A staggering prevalence of depression (70-80%) and anxiety-related disorders (40-70%), especially in the third trimester of the pregnancy have been reported 2,10. These can be precipitated by the psycho-social adversities and high-stress levels inside the prisons 10.

Studies have reported that around 60-90% of pregnant women in prisons use substances and around 30-40% have illicit substance use 2. Interestingly, most women are arrested for non-serious offences and 25-50% of women are incarcerated due to drug-related offences (such as possession and trafficking) 11. Tobacco, alcohol, opioids and cocaine are among the popularly used substances.

Personality disorders are reported to be highly prevalent among incarcerated women (not specific to pregnant women) ranging from 38-45%, but rates might be similar in pregnant incarcerated women 2. The COVID-19 pandemic offers a surfeit of new challenges such as the need for physical distancing (in prisons that are often overcrowded), logistical barriers due to lockdowns, delay in referrals, change in child delivery plans, lack of support staff during delivery, reduced physical contact with the family, delay in trial proceedings, elevated mental health issues, and worries related to the well-being of the child.

Incarcerated pregnant women are a custodial minority with specific needs who also have to cope with higher levels of stress. It is important to understand that many women in prisons have faced trauma and come from various complex backgrounds involving domestic violence, homelessness, poverty, substance abuse, poor education, and neglected parenting. These vulnerabilities put them and the subsequent generations at risk of transgenerational trauma.

Worries and parental concerns among mothers to be in prison might be unaddressed as they do not have their mothers and counsellors by their side as they would have in the community. Maternal stress, depression and anxiety may contribute to poor compliance with ante-natal care and adverse pregnancy outcomes 2. There is an elevated risk for spontaneous abortions, pre-term delivery, and low birth weight 12,13. As a result, outcomes such as attachment-related issues, a spectrum of learning, behavioural, interpersonal issues, and neuro-psychiatric adversities have been reported in children born to women in prisons12.

Studies have also shown that women in prisons have a higher likelihood of unplanned pregnancy 4. They may not have facilities or be informed about the options of adoption, medical termination of pregnancy or contraception inside prisons 4. The multifaceted stigma starts with “being a criminal”, “being a female criminal”, “being a pregnant female criminal”, “being a criminal with an infant” and extends up to dehumanization of these individuals based on a plethora of negative stereotypes.

Studies have reported poor quality of perinatal care inside prisons 14. In India, women nearing their pregnancy term, are generally required to be sent on parole/bail and they return to the prison, a few days after the delivery with the infant 3. However, it is important to understand pregnancy and the postpartum period as a process and not as an outcome, which is childbirth. For example, what if a pregnant woman experiences a spontaneous abortion or a sudden absence of foetal movements that were earlier felt normally? Also, in the post-partum period, we are aware of the important aspects related to trauma, bonding, attachment and their long-term impact on a child.

These scenarios highlight the importance of reproductive justice, the need to holistically view the requirements of a mother-fetus dyad or a mother infant dyad and not to view pregnancy as merely an act of child birth. The Supreme Court of India in 2006 passed a ruling that all prisons should have cradles (for infants), creches (for children up to 3 years of age), and nurseries (for children between 3-6 years of age), preferably outside the prison premises 15.

However, according to available information only a few states such as Andhra Pradesh, Gujarat, Tamil Nadu and Delhi have provisions for creche and nursery facilities for children inside the prisons 9. As of December 2019, 1,779 children were staying in the prison with their mothers in India 9.

A prisoner is required to be treated as a human being, entitled to all human rights, including the right to autonomy and dignity. It is important to realize that an incarcerated pregnancy and custodial childbirth is a fundamental violation of reproductive justice. It is the right of any child to be born in a conducive environment. Unfortunately, these rights are barely recognized and are far from being protected 4. This may just be the tip of the iceberg, the systematic and systemic injustice met by these vulnerable women can sink the ship of envisaged rehabilitative and restorative purposes of prison.

Various structural and administerial barriers complicate the care of pregnant women in the prisons such as overcrowding, restrictive environments, poor nutrition, lack of antenatal care, lack of women-centred facilities, lack of standard operating guidelines such as routine pregnancy tests for incoming women prisoners in the reproductive age group, delay in transportation of women to medical facilities, and lack of support from staff 2,10. Shackling may restrict mobility, delay interventions especially in obstetric emergencies, increase the risk of blood clots, impair mother-infant bonding, and produce severe anguish 16,17.

“.. I was bleeding like so bad, and they only gave me one pad. They only gave me one pad the whole time, and my pants, I had blood everywhere…it took them hours before they called an ambulance and took me to the hospital, and then they found out I miscarried.” 18

The Indian National Model Prison Manual (2016) has provisions on pregnancy and childbirth in prisons. These measures include addressing the nutritional needs of pregnancy and lactation period, pregnancy testing, prohibiting the use of restraints, ensuring adequate antenatal care, having access to abortion, autonomy and decision making in terms of the nature of work mothers would like to take up, and temporary release from prisons for child birth in a hospital. The Ministry of Home Affairs vide advisory dated 4th May 2017 advised the State Governments and Union Territories that they revise their existing Prison Manuals by adopting the provisions of the National Model Prison Manual (2016) 3.

Internationally, there are some models that can be emulated. These include the Motherhood Beyond Bars in Georgia and the Women and Infant at Risk in Michigan. The Doula birth support programs for incarcerated pregnant women have reported positive results in terms of delivery outcomes and satisfaction 4.

To find a bit more about what really happens in Indian prisons, we contacted Dr Santhosh Jayashankar, a psychiatrist in the Central Prison Bangalore (reporting with consent). He said “All women less than 50 years of age who come to the prison are screened for pregnancy and mental health issues upon entry. If needed a woman is referred to a specialist care centre for confirmation of pregnancy and regular antenatal visits. Mental health issues are addressed by the prison psychiatrist and a referral to a specialist psychiatry service is facilitated if required. Nutrition is provided as per the Antenatal Care (ANC) guidelines. Video conferencing call under supervision is facilitated weekly to contact the family.

Women in their third trimester are housed in the women prison hospital for round the clock observation. Trained female police warders facilitate regular monitoring of vitals, supervise medications and alert the medical officers if deemed necessary. Therefore, prison female medical officers, trained female police and the gynaecologist based in a tertiary care hospital, jointly provide the ANC care.

Women are transferred to the tertiary care hospital at term for delivery and their family is informed and allowed to be with them. Post-delivery, the mother along with her family jointly decide if the baby will continue staying with her in the prison (allowed till the child turns 6 years) or be handed over to the family. If the child’s mother or family are unable to provide care, the child is handed over to the Child Welfare Committee (CWC).

The child’s immunisation and other health needs are met through a Paediatrician referral and regular visit of a nurse from a PHC in the vicinity. Convicted female prisoners are important sources of support as they handhold the mothers through their own experience of mothering. There is a designated teacher and play area for all the toddlers. Children between 3-6 years of age are sent to Anganwadi and a government school near the prison campus.

It is evident that for the mental health of mothers and positive dyadic relationships between mother and infant, incarcerated mothers need to be provided specialised services to reduce maternal stress and stigma. Regular contact with family and free legal aid services should be facilitated. Screening and addressing mental health issues and substance abuse in pregnant and post-partum women would be vital. We also need to ensure that they get respectful maternity care when in prison and during childbirth.

The infant’s mental health needs should be addressed such as assessing for drug withdrawal/discontinuation symptoms post-delivery, developmental assessments, and mother-infant bonding. Previous studies from the west have highlighted the importance of mother-baby units inside prisons, and these should be set up in the Indian prisons as well.

Unfortunately, unlike the Central Prison in Bangalore, many prisons in India do not have a mental health professional and depend on other mental health establishments to cater to the psychological and psychiatric health needs of the prisoners. Sensitizing prison staff and convicted female prisoners about the mental health requirements and identifying common signs and symptoms of mental illness in incarcerated pregnant and postpartum women, could build capacity of prison staff. Asking women prisoners what they need and involving them in planning these services is essential. Research shows that pregnancy outcomes are affected by facility-specific circumstances in the prisons and thus, open vistas for reparative and remedial measures to mitigate adversities in these custodial minorities.

Childbirth is undoubtedly the most treasured and precious memory of a mother but can also be traumatic. As mental health professionals we need to advocate for better services and facilities for pregnant and postpartum women in prisons.

References

1 Abbott L, Scott T, Thomas H, Weston K. Pregnancy and childbirth in English prisons: institutional ignominy and the pains of imprisonment. Sociology of Health & Illness 2020; 42: 660.

2 Mukherjee S, Pierre-Victor D, Bahelah R, Madhivanan P. Mental health issues among pregnant women in correctional facilities: a systematic review. Women & health 2014; 54: 816–42.

3 Women in Prison India. 2018.

4 Friedman SH, Kaempf A, Kauffman S. The Realities of Pregnancy and Mothering While Incarcerated. The journal of the American Academy of Psychiatry and the Law 2020; 48: 365–75.

5 Sleed M, Baradon T, Fonagy P. New Beginnings for mothers and babies in prison: a cluster randomized controlled trial. Attachment & human development 2013; 15: 349–67.

6 Shaw J, Downe S, Kingdon C. Systematic mixed-methods review of interventions, outcomes and experiences for imprisoned pregnant women. Journal of advanced nursing 2015; 71: 1451–63.

7 Walmsley R. World Female Imprisonment List fourth edition Women and girls in penal institutions, including pre-trial detainees/remand prisoners. 2018. www.prisonstudies.org. (accessed Oct 17, 2021).

8 Ghidei L, Ramos SZ, Brousseau EC, Clarke JG. Prison: Pipeline to Women’s Preventative Health. Rhode Island medical journal (2013) 2018; 101: 23.

9 Prison Statistics India, 2019 | National Crime Records Bureau. 2020. https://ncrb.gov.in/en/prison-statistics-india-2019 (accessed Oct 17, 2021).

10 Dolan R, Hann M, Edge D, Shaw J. Pregnancy in prison, mental health and admission to prison mother and baby units. https://doi.org/101080/1478994920191586978 2019; 30: 448–66.

11 Peeler M, Fiscella K, Terplan M, Sufrin C. Best Practices for Pregnant Incarcerated Women With Opioid Use Disorder. Journal of correctional health care : the official journal of the National Commission on Correctional Health Care 2019; 25: 4.

12 Wu Y, Lu Y-C, Jacobs M, et al. Association of Prenatal Maternal Psychological Distress With Fetal Brain Growth, Metabolism, and Cortical Maturation. JAMA Network Open 2020; 3: e1919940–e1919940.

13 XX D, YL W, SJ X, et al. Maternal anxiety during pregnancy and adverse birth outcomes: a systematic review and meta-analysis of prospective cohort studies. Journal of affective disorders 2014; 159: 103–10.

14 Sufrin C, Beal L, Clarke J, Jones R, Mosher WD. Pregnancy Outcomes in US Prisons, 2016–2017. https://doi.org/102105/AJPH2019305006 2019; 109: 799–805.

15 Prisons must have creches: SC | India News – Times of India. https://timesofindia.indiatimes.com/india/prisons-must-have-creches-sc/articleshow/1489640.cms?from=mdr (accessed Oct 18, 2021).

16 Thromboembolic Disease in Pregnancy and the Puerperium: Acute Management Green-top Guideline No. 37b. 2015.

17 Committee opinion no. 511: Health care for pregnant and postpartum incarcerated women and adolescent females. Obstetrics and Gynecology 2011; 118: 1198–202.

18 Liauw J, Jurgutis J, Nouvet E, et al. Reproductive healthcare in prison: A qualitative study of women’s experiences and perspectives in Ontario, Canada. PLoS ONE 2021; 16. DOI:10.1371/JOURNAL.PONE.0251853.

Dr. Bhavika Vajawat is a Senior Resident in Forensic Psychiatry at the Department of Psychiatry, NIMHANS.

Dr. Prabha Chandra runs the Perinatal Psychiatry Services as well as the NIMHANS Centre for Well Being at the National Institute of Mental Health and Neurosciences, Bangalore, India. She is President Elect of the International Association of Women’s Mental Health, and has expertise in areas of women’s mental health, the mental health impact of partner violence and perinatal psychiatry.

Curated by Centre for Mental Health Law & Policy

 



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