Birth Behind Bars: The Complexities of Pregnancy in Prison
Except for occasional exposés and short-lived reform efforts, prison medicine has gone without public scrutiny… Outside of prisons and jails, health care providers and facilities have been inspected, licensed, certified, maintained, and regulated. Within the walls, in sharp contrast, almost anything could go on (Prout et al. 228).
Introduction
Many incarcerated women in the United States have had pregnancy experiences that could be considered inhumane, from not receiving recommended treatment to being restrained during childbirth. The standards of maternal healthcare in prisons warrant examination, as there are many shortcomings to be addressed. This project will focus on maternal healthcare for incarcerated women, including the related topics of available healthcare resources, prenatal care, gender disparities, and criminal justice. Reflecting on the injustices that occur in correctional facilities nationwide brings up an important ethical question: how can the ethical shortcomings of pregnancy healthcare in prisons be addressed? There are multiple complexities involved that need to be considered. The prison population is the only group in the United States that is guaranteed healthcare. Outside of prisons, healthcare is granted through private companies and government aid, which both have different standards and levels of care. In prisons, though, inmates are considered to be in the custody of the state, and the government must determine the standard of healthcare that is provided. Even once laws and financial decisions are made, there are logistical challenges in implementing and enforcing a certain standard of care. Society also often has a perception of prisoners as being deserving of subpar living standards, which raises the question of whether it is ethical for healthcare standards to change depending on who they are applied to. The issue is further complicated by the fact that the level of maternal healthcare for incarcerated women affects not just the woman, but also a potential child. As such, appreciating the full depth of the topic will involve a thorough understanding and ethical analysis of a variety of factors.
The ethical aspects of this topic can be effectively analyzed through the lenses of frameworks like consequentialism and principlism. Consequentialism will be important for separating actions from consequences, and it will put ethical value on the outcomes of decisions rather than more arbitrary inclinations for how people should be treated. Principlism is a very relevant framework for analyzing bioethical topics, and it will allow for a nuanced analysis, because its four principles are often at odds in these topics. Ultimately, this project will result in an ethical examination of shortcomings associated with how pregnancy related healthcare is provided currently; an analysis of potential solutions using consequentialism, principlism, and relevant stakeholders; and final recommendations for ethical legislative and policy changes for prisons.
Current Prison Healthcare Practices
Gender Disparities
American prison healthcare has multiple gender disparities that present barriers for incarcerated women, which can be attributed to the fact that women are a minority in prisons. Since men have historically been incarcerated at much higher numbers than women, correctional facilities have mainly been designed with their needs in mind. However, in recent decades, there has been a seven times increase in incarcerated women, from roughly 26,000 to over 180,000 (Budd), an upsurge much higher than that of incarcerated men (Rogers 201). This means that there has been a gradual decline in the prison population’s gender difference. With the extreme increase in incarcerated women this country has seen over the last few decades, it’s essential to reexamine the prison system and its gender differences. This can be accomplished by considering the unique healthcare needs that women have.
One of these needs is reproductive healthcare related to pregnancy, as this presents a unique health need for women and contributes to women’s higher healthcare usage. Incarcerated women also have a higher rate of chronic conditions than incarcerated men, and this difference doesn’t align with chronic illness rates of the general population (Udo). It is unclear why this difference is only seen for the incarcerated population. These gender disparities illustrate some of the challenges women face in receiving adequate healthcare in prisons. These barriers and the fact that prisons weren’t designed with women in mind are why it’s especially important to examine and reform healthcare for pregnant inmates.
The disparities become especially impactful at prisons which require copayments. Due to the high costs of correctional healthcare and a desire to reduce medical visits, many prisons began implementing copayments during the 1990s. Today, all U.S. federal prisons require payments by inmates of around $2-8 for non-emergent medical visits (Wyant et al.). Copayments can represent an extreme financial burden for the incarcerated. Though the costs are low, prisoners are often unemployed or have a very low income for any work they do while incarcerated.
In general, incarcerated women end up being more negatively affected by these copayments. Incarcerated women have a higher rate of health care usage than incarcerated men, but prison copayment amounts are usually the same for everyone. A study on the use of copayments in prisons found that women are 50% more likely than men to avoid medical visits due to the cost. One woman who was interviewed for the study said, “I need to be seen but will not go because I can't afford it” (Wyant et al.). Copayments create an especially difficult barrier to healthcare for incarcerated pregnant women, as women are recommended to attend routine obstetric visits during pregnancy. In fact, pregnant women in correctional facilities with high copays are three times more likely to forgo an obstetrical examination while incarcerated than those in facilities with no copayment (Widra). Gender disparities in prison healthcare are important to explore because they can affect the treatment of pregnant inmates.
Pregnancy Related Healthcare
An estimated 5% of women admitted to correctional facilities are pregnant (Sufrin et al.). While this is a small percentage, it represents thousands of women with important healthcare needs, and these needs are often not met. Most jails and prisons don’t provide adequate obstetric care (Rogers et al. 201), and 9% of incarcerated pregnant women have not received an obstetric exam since admission (Widra). Additionally, there is a lack of national data related to incarcerated pregnant women, including prevalence and fetal outcomes (Sufrin et al.). This lack of data presents a challenge in drawing clear conclusions about the quality of reproductive healthcare for incarcerated women and illuminates the widespread absence of attention towards it. The United States has an evident pattern of lacking adequate healthcare resources for incarcerated women that is likely partially due to the lower number of women in prisons compared to men and the fact that things like reproductive care are difficult to provide in a prison environment.
To understand how pregnancy related healthcare currently operates in the United States and what it’s like to be pregnant in prison, let’s use a hypothetical scenario of a pregnant woman in the prison system. Imagine a 32-year-old woman named Leah who is serving a two year prison sentence at a prison that doesn’t require pregnancy tests upon admission. Unbeknownst to her, she was one week pregnant when she entered the prison. She has not been in contact with the father of her child for weeks, her only living parent is also in the prison system, and her sister lives in a different state. The quality of healthcare Leah receives during and after pregnancy will affect the physical and mental health of her and her future baby. Considering the importance of proper healthcare treatment during pregnancy, a coordinated treatment plan is essential for successful outcomes. Fortunately, there are readily available recommendations for providing high-quality maternal healthcare.
The American College of Obstetrics and Gynecology (ACOG) is a reputable organization for obstetrician–gynecologists that was founded in 1951 and has over 60,000 members. It is generally accepted that following the ACOG guidelines for the care of incarcerated pregnant women should be the standard for high-quality care (Puisis 182). In the guidelines’ section about incarcerated women, the ACOG outlines some recommendations for adequate prenatal care and treatment of pregnant inmates. These recommendations include routine visits with a healthcare professional during pregnancy, privacy during examinations and labor, and delivery at an appropriate healthcare facility. The ACOG also strongly advises against shackling pregnant inmates except in very specific circumstances, in which case a healthcare professional should be consulted first (Kilpatrick). Looking at the ACOG guidelines versus actual healthcare practices in prisons will provide a useful comparison that will reveal shortcomings of the system.
The first step of pregnancy related healthcare is prenatal care, for which early intervention is necessary for positive long term outcomes. Despite this, only 38% of U.S. jails test women for pregnancy upon entry (Hutchinson-Colas et al.). A delay in pregnancy detection limits the prospects of early prenatal care intervention, which can increase the likelihood of poor pregnancy outcomes. The quality of prenatal care a fetus receives can have both short and long term health implications on the child’s life. For example, poor diet and nutrition during pregnancy can lead to fetal complications such as neural tube defects, premature birth, and low birth weight. Dehydration can also elevate the risk of preterm labor and contractions.
Typical prison diets can lack certain essential nutrients, and testing for pregnancy upon intake is a recommended solution to ensure necessary diet adjustments are made (Nair et al.). Since Leah didn’t receive a pregnancy test upon admission, she doesn’t discover her pregnancy until she is four weeks pregnant, when she starts experiencing more symptoms and was able to request a test from the prison infirmary. This delays the start of obstetric care, and due to the prison’s unclear policies, she doesn’t attend her first obstetric visits until after two months of pregnancy.
When it’s time for incarcerated pregnant women to deliver their babies, many prisons make use of shackling, as the women are often leaving the security of the prison. The term “shackling” is typically used to describe the use of restraints on incarcerated pregnant women during the process of labor and delivery (States of Incarceration) and is often used for inmates who are under high security or are considered a flight risk. Some states have introduced laws to restrict this practice during certain stages of pregnancy, but it is still common in many prisons. Many of these laws also only restrict shackling in some scenarios. For example, only 15 states have banned shackling throughout pregnancy, labor, delivery, and postpartum recovery, and other states may have less restrictive laws. Even states that have anti-shackling laws don’t always see the rule being enforced (ARRWIP).
Shackling during pregnancy, especially labor, is associated with various risks and harms (Dufresne). One risk that arises from the practice of shackling pregnant women is falling, as certain restraints can inhibit balance and make it more difficult to break a fall. Falling has more severe effects during pregnancy, as there is the potential for harm to the fetus. Shackling can also delay medical treatment in the case of complications. There are a multitude of life-threatening conditions that can occur during childbirth, and immediate treatment by physicians is crucial for addressing unexpected complications. The need to remove restraints can slow the necessary medical intervention. There are also complications that can arise from restricting movement. Pregnant women are at risk of developing blood clots during delivery, especially while staying in one position for an extended amount of time, and shackling can increase the risk of post-delivery deep vein thrombosis. Finally, there are possible psychological harms to consider. Shackling can be a degrading practice for pregnant women, who are often already experiencing a vulnerable mental state in the period before and after delivery due to the potential of developing postpartum depression.
Once the babies of incarcerated women are born, their outcomes can be unclear. Most prisons require that the pregnant inmates are taken to a local hospital after signs of labor in order to give birth outside the prison, but there is often separation early on between the mother and newborn. This practice is largely unique to the United States, as it is one of the only countries that routinely separates incarcerated mothers from their newborns (Nair et al.). In some cases, childcare arrangements with relatives are made, but the child might also be placed into foster care, and the mother could eventually lose permanent custody (Sametz 298). Children of incarcerated women are more likely to go into foster care than those of incarcerated men. Since Leah doesn’t have close contact with relatives, she isn’t able to create childcare arrangements for her newborn. The prison informs her that her baby will be placed in the custody of the state for the remaining two years of her sentence, and the baby is taken away a few minutes after birth.
The increase in women giving birth in prisons over the last few decades has urged many correctional centers to adopt new systems for handling these cases. Decatur Correctional Center in Illinois is one facility that has implemented a radical new program which allows incarcerated women to raise their babies for up to two years in prison nurseries, also known as Mother-Baby Units (MBUs). Destiny Doud, one of the first to participate in the new program, said that getting to raise her daughter gave her “something to live for,” and she’s hoping to break her family’s generational pattern of incarceration (Jouvenal). Many MBUs provide parental education and counseling to mothers, which arrives at a crucial time in newborns’ development. Another benefit of having prison nurseries is that mothers aren’t immediately separated from their children, allowing them to maintain a maternal bond. It’s clear that this has a positive effect on some prisoners, as was the case with Doud, whose ability to stay with her daughter gave her hope and a desire to make important life changes.
In fact, New York, Washington, and Nebraska saw decreased reincarceration rates after implementing MBUs, and a similar pattern was exhibited in a 2016 study (Nair et al.).
On the other hand, there are a few downsides to this system. It could be argued that allowing babies to live in a prison environment simply isn’t suitable for them. While Decatur Correctional Center is low security and not designed for dangerous inmates, babies would still be placed in the care of people who have been convicted of crimes, which could lead to questions of if those who are incarcerated should be entrusted with the responsibility of parenting. Additionally, prison nurseries aren’t a perfect solution for allowing a mother-child bond to remain, as these programs typically only allow the child to stay for less than two years. It could potentially be more painful for both the mother and child to be separated after they’ve spent years together. However, in Leah’s case, and for others serving shorter sentences, a prison nursery could have allowed her to remain with her baby until the end of her sentence.
Essentially, prisons around the country have a variety of systems for addressing the healthcare needs of incarcerated pregnant women, with many causing inadvertent harms and risks that warrant examination. Copayments create barriers to healthcare visits; many women don’t receive early prenatal intervention or the recommended amount of obstetric visits; restraints are sometimes used during pregnancy, despite shackling bans; and many mothers are immediately separated from their newborns, which can be an emotionally difficult process. Leah’s experience was hypothetical, but it mirrors many of the challenges incarcerated pregnant women face when receiving medical treatment. Addressing these issues can be accomplished through the use of healthcare standards for prisons. Unfortunately, implementing fair but strict standards that are consistently followed can prove to be very challenging.
Legislating Prison Healthcare Standards
Legal and Financial Systems
How are ethical healthcare standards determined at the federal level? Healthcare has to be regulated both legally and financially. In terms of the legal side, healthcare is a constitutional right for the prison population. In the 1976 Supreme Court ruling of Estelle v. Gamble, it was decided that deliberate indifference to the medical needs of inmates violates the Eighth Amendment, which restricts any form of cruel or unusual punishment. While this right is a legal guarantee, upholding and enforcing it can present practical challenges. Curtis Prout articulates the issues that arise when attempting to legislate a standard of care for the incarcerated population in the ethics and correctional medicine book, Care and Punishment: The Dilemmas of Prison Medicine:
Prisoners are entitled to the best health care available. The courts have said that this right is guaranteed by the Constitution… They are placed in institutions as punishment. The courts have decreed that there be no cruel and unusual punishment and that denial of access to adequate medical care is, in fact, cruel and unusual punishment. Nowhere have court decisions or class action suits guaranteed improvement, correction, or reform of the individual. The term “care” is used loosely… Standards can insure everything but these intangible, yet necessary, aspects of adequate medical care. Society has not been able to legislate warmth and compassion and probably most citizens feel no necessity to supply these to prison inmates (Prout et al. 228-229).
Evaluating prison healthcare is challenging because of the “intangible” aspects of care. The relationship between a physician and a patient is a central aspect of healthcare, but it is an aspect that can’t be regulated in the same way other things can. Clinical Practice in Correctional Medicine describes how the existing standards of prison healthcare “provide minimum requirements necessary to operate a medical service” and are “more administrative than clinical in nature,” which further demonstrates the dilemma of addressing the opposite goals of correctional facilities and medical care (Puisis ix). The financial element of legislating prison healthcare is similarly challenging.
An article from Public Administration Review on the effects of judicial decisions on prison budgets described how strained these budgets are and how costly funding for prison reform is. According to the article, certain court orders can cost prisons anywhere from $5 million to $1 billion. Former Director of multiple Departments of Corrections Allen L. Ault stated that correctional institutions are struggling with limited budgets, while grappling with judicial orders for increased spending and limited public support of prison reform. Due to the increasing rates of incarceration over time, higher prison budgets don’t always lead to higher spending per prisoner (Harriman et al.). An important note is that many courts have upheld that financial constraints are not a defense for inmates lacking rights guaranteed to them by the Constitution. In the landmark 1974 case Gates v. Collier, the court determined that “shortage of funds is not a justification for continuing to deny citizens their constitutional rights” (Harriman et al.). In other words, adequate healthcare standards should not be contingent on a prison’s financial situation, and despite the severely limited healthcare budgets some correctional facilities face, this shouldn’t affect the standard of care. Choices related to funding could indirectly affect other possible destinations of funding, which is why determining healthcare budgets for prisons is a difficult balance. Most prisons don’t have sufficient funds to provide all necessary aspects of healthcare, but as is outlined in Gates v. Collier, low prison budgets should not influence incarcerated individuals’ Constitutional right to healthcare. So how can prisons reasonably provide healthcare while under financial constraints? It is seemingly necessary for federal and state governments to allot more resources into prison budgets in order to ensure this law is followed. Overall, it is difficult to legislate a high quality of healthcare for the prison population, both legally and financially.
Determining Standards of Care
Of course, this is assuming that prison healthcare should be held to the highest possible standard. Should incarcerated people even be granted an equal level of healthcare as the general population? It’s worth considering the fact that no blanket statements can be made about the integrity of people who are incarcerated. It is not as simple as determining what all incarcerated people “deserve.” First of all, not everyone is in prison for the same reason, as there is the possibility of being falsely accused and a difference between violent and non-violent crimes. For example, a majority of incarcerated women were convicted of non-violent crimes, and histories of trauma and abuse are common as well (Sufrin). This makes judgment of incarcerated women complicated and nuanced. Furthermore, the quality of care for incarcerated pregnant women affects both the woman and the fetus or baby, so decisions related to maternal healthcare should consider the fact that both an incarcerated woman and an innocent life are being affected. On the concept of “deserving” treatment, it’s not entirely clear whether punishment is even the main purpose of a prison, and if that would warrant subpar healthcare standards for the incarcerated. As stated in Care and Punishment: The Dilemmas of Prison Medicine, “there is the major conflict of care and punishment that is a fact of life in prison medicine. This central irony colors all health care in jail and prison: the same institution that is responsible for punishing offenders is also responsible for giving them the care they need” (Prout et al. 228). The responsibility of the government to provide inmates with the care they need is due to the fact that people who are incarcerated are within the custody of the state, and it is the state’s role to provide necessities. Considering the fact that prisons are not meant to be a positive environment, should there ever be a lack of attention towards inmates’ needs?
Humane Health Care for Prisoners: Ethical and Legal Challenges holds the view that from an ethical standpoint, the “punishment” of incarceration shouldn’t include withholding medical care: “in keeping with the norm of beneficence, which requires the medical practitioner to intervene only for the purpose of accomplishing some good for the patient, the denial of medical care never should be used or even appear to be used as punishment, as was previously stated. Incarceration itself is the punishment imposed by law… One does not ‘earn’ an entitlement to health care, nor does one become unworthy of medical treatment because of bad behavior” (Faiver 190). This position is based on a belief that healthcare is a fundamental human right that shouldn’t be denied under any circumstances. The prison system could be argued to have various purposes, including deterrence, isolation of dangerous individuals, rehabilitation, and punishment. Even if punishment is taken as one of the primary purposes of incarceration, a lack of medical care shouldn't factor into that punishment, as being in prison is punishment enough, and it is the government’s responsibility to properly provide for the needs of people in its custody. Physicians should not have to play judge and jury, and their duty of medical care should not be inhibited by the prison system.
Biases and Unequal Treatment
On the other hand, prison physicians might have to view their practice differently than those who treat the general population, and prison medicine might greatly differ from other forms of medicine. According to Care and Punishment: The Dilemmas of Prison Medicine, “prison health care is made more unlike other health care settings by the thick atmosphere of paranoia. Mutual distrust sours all relationships.” Prison physicians cannot simply practice medicine the way they would in a different environment: “if the prison physician similarly ignored the environmental factors of prison life, the practice of medicine behind bars would be severely hobbled. To protect himself against the conniving and self-seeking inmates, the physician needs… a clear sense of what the inmate’s game is…. Just as the inmates are likely to make much of nothing, in the interest of stirring up trouble or simply to get attention, so inmates are likely to withhold important medical information if they think that revealing it will put them in jeopardy. In either case, the prison physician must take the inmate’s information with a great deal of skepticism” (Prout et al. 138). The source claims that in order for physicians to be able to effectively practice prison medicine, they can’t treat inmates like any other patient, because of their “conniving and self-seeking” nature and likelihood to be dishonest about medical information. This raises the question of whether it is just to have this automatic bias about incarcerated patients. A physician being overly skeptical about a patient’s words could potentially disrupt the medical process, as an honest and trusting relationship between a physician and a patient is crucial for adequate care.
Clear communication and trust is especially important for incarcerated pregnant women, as becomes apparent when examining cases such as that of Kelsey Love. In 2018, Love was a pregnant inmate at Kentucky's Franklin County Regional Jail. Early one morning, she reportedly complained of labor pain to an officer, and said that the baby was coming. It wasn’t until almost three hours later that a nurse arrived at Love's cell, where she had already given birth alone, with no medical personnel present. The prison was ultimately required to pay Love $200,000, but the jail and its employees were not required to admit responsibility for the incident. Moreover, there is no evidence that meaningful policy changes have been made at the jail since (Branigin). The incident stemmed from the officer not effectively communicating Love’s labor concerns, and similar lapses in communication relating to labor have occurred in jails around the country. This case reveals the potential harms of being overly skeptical of and less perceptive to the medical information provided by incarcerated individuals and lacking the necessary urgency for their care.
The treatment of incarcerated women not only involves healthcare policies but also the seemingly inconsequential convention of how the “patients” are referred to by prison staff and physicians. What is it like to be an “inmate” and a “mother”? Kenneth Faiver’s Humane Health Care for Prisoners argues that even the terms used for someone being treated can affect a physician’s response. According to the text, “health care professionals respond almost instinctively to assist and benefit their patients. Terms such as prisoner, inmate, offender, delinquent, or detainee simply do not elicit the same automatic response” (228).
Faiver further asserts that even words with less negative associations such as resident or student (for juvenile facilities) don’t induce the same healing response as the conventional healthcare term, patient. Labels can be an important part of how someone sees themselves and their role. When a pregnant woman is given the label “mother,” it invokes a certain sense of duty and responsibility. It’s important to understand the fact that patient care requires a holistic approach, and healthcare practitioners have a sacred duty to treat each patient to the best of their ability, which is why it is crucial that incarcerated women receiving pregnancy-related healthcare should be viewed more as patients than as inmates.
All in all, practicing medicine in a prison environment is challenging, as it can seem to contradict the prisoner status of the patients, conjure up questions about deservedness and fairness, and cause physicians to operate based on biases and skepticism about the medical information provided by patients. Thus, the nature of personal interactions between physicians and patients is just as important as the legislative and financial sides of correctional medicine.
Ethical Considerations and Solutions
In conclusion, researching maternal healthcare for incarcerated women in the United States has identified a few main shortcomings of the system. These issues warrant government-sanctioned solutions involving funding and legislation changes. One of the main problems with maternal healthcare is the lack of regulation in prisons across the country. Evidence has suggested that healthcare in correctional facilities varies greatly between regions, which can be owed to the challenges of interpreting mandated healthcare standards, as they are only vaguely described in law. Estelle v. Gamble ensures that healthcare is provided, but doesn’t guarantee fair or unbiased treatment of inmates by physicians. This has led to some facilities committing egregious human rights violations with minimal consequences, such as in the case of Kelsey Love. Another widespread issue is that incarcerated women receiving pregnancy-related care aren’t always treated as patients. This extends to the language used to describe them, treatment by healthcare staff and prison guards, and the rights they are granted. Finally, cases of pregnancy and birth in prisons aren’t well documented, leading to a lack of information surrounding morbidity and mortality. The data we have reveals that the recommended standards of obstetric care for pregnant inmates aren’t followed, due to a lack of routine medical visits, barriers to accessing healthcare resources, and harmful practices such as shackling during labor and delivery.
An ethical analysis of these issues involves a few main stakeholders: incarcerated mothers and their mental and physical health; children born to incarcerated mothers, whose health outcomes will be impacted by prenatal care and the system of childcare after birth; and finally, other recipients of government funding, because increasing government spending on pregnancy healthcare can come at the expense of other government initiatives. The ethical frameworks consequentialism and principlism guided my thought process when analyzing the ethics of pregnancy related correctional healthcare. Consequentialism puts weight on the consequences of a potential decision rather than just basing it on the associated principles. When considering the treatment of pregnant inmates through this lens, there is less of a focus on what incarcerated women “deserve.” Instead, a decision is only based on how it affects stakeholders. Principlism relies on adherence to four main bioethical principles: beneficence, non maleficence, justice, and autonomy. Justice and beneficence were the principles I found most relevant to my topic.
Adhering to beneficence would involve focusing on what will benefit the health of incarcerated mothers and their children. Numerous studies have demonstrated the harms that can stem from pregnant women not receiving the recommended medical treatment through all stages of pregnancy (Kilpatrick; Nair et al.). It is clear that adhering to beneficence for incarcerated pregnant women involves upholding high standards of healthcare so that these harms can be mitigated. A high quality of healthcare is beneficial to the person being treated, and doesn’t detract from the goals of incarceration. It is crucial for the goals of healthcare and prisons to be separated, so each can be adequately accomplished. Prison physicians should see those they treat as any other patient, which extends to the language used to describe them. Ensuring the optimal treatment of newborns becomes slightly more complicated, as there is debate about the fate of the child after birth. Implementing MBUs in prisons would benefit mothers, because they would be able to maintain a bond with their newborn and potentially have lower chances of reincarceration. It is not completely clear whether MBUs are the most beneficial living situations for the newborns, but the demonstrated success of MBUs in various states seem to indicate that they don’t pose a significant harm.
When considering justice, I thought about a sense of fairness for healthcare access, and the fact that the prison population is guaranteed healthcare, while the general United States population is not. This disparity could be considered unjust, as some would argue that people who have been convicted of crimes shouldn’t be “prioritized” over the general population in terms of healthcare. This also involves other recipients of government funding as a stakeholder, because increased prioritization and funding of correctional healthcare could potentially detract from funding to other areas. However, it is important to consider how this relates to the concept of criminal justice, which is the system that addresses crime and enforces consequences for citizens who break the law. Our prison system addresses the concern of justice for incarcerated individuals, and as stated in Humane Health Care for Prisoners: Ethical and Legal Challenges, “denial of medical care never should be used or even appear to be used as punishment, as … incarceration itself is the punishment imposed by law” (Faiver). Criminal justice and correctional healthcare are separate issues that should not be conflated. Prison budgets are also already severely limited, and in order to ensure that healthcare standards are upheld, financial support for prison healthcare should not be decreased any further.
Analyzing the ethics related to maternal healthcare for incarcerated women through the lenses of principlism and consequentialism informed my personal opinion about the issue. It is evident that reform is necessary. In my opinion, there needs to be a change in how pregnant prisoners are regarded by prison staff. Taking any liberties with the medical treatment of pregnant women can lead to drastic consequences, which is why it’s so important for incarcerated pregnant women to be treated as patients rather than inmates. Physicians have a sacred duty to provide fair treatment which can only be fulfilled if prison practices don’t interfere with treatment. Requiring pregnant prisoners to pay high copays for recommended obstetrics visits and interfering with treatment with practices like shackling detract from this goal.
Certain key legislation changes would be able to implement these suggestions and combat correctional healthcare shortcomings. First of all, the anti-shackling ban should be implemented in all states and enforced more strictly. Currently, the law is not effective in maintaining its original purpose. Many obstetric-gynecologists have provided insight into the medical needs of pregnant women, and due to the necessity of routine visits, incarcerated pregnant women should be guaranteed to have an obstetric visit every month of pregnancy with no copay. Finally, it is important that data regarding pregnancy in prison is tracked carefully to look for concerning patterns related to prison practices, morbidity, and mortality. In order to address separation after birth, MBUs should be implemented in all low security correctional facilities. While they are not yet common in the U.S., most countries do not immediately separate incarcerated mothers from newborns. The implementation of prison nurseries has already demonstrated success in multiple states (Nair et al.), and the resulting risks and downsides can be largely mitigated through careful moderation of these environments. The benefits of maternal bonding and parental education are important enough to warrant these changes. Overall, fetal and maternal healthcare for incarcerated women is in need of reform, but there is a clear path forward towards making the necessary adjustments.
Conclusions surrounding healthcare for incarcerated pregnant women extends to similar ethical topics and reveals broader systemic issues. The group of people that this paper focused on is one example of a vulnerable population in the United States that struggles with healthcare access, but many other such groups exist in this country, including people of low socioeconomic status or people who live in rural areas where resources are less accessible. Many elements of our healthcare system come down to what the responsibilities of the government are and what they should be. It needs to be decided whether high-quality healthcare should be considered a fundamental and guaranteed right, as this would warrant more widespread changes. In a political landscape where the topic of universal healthcare remains extremely contentious, answering this question is both challenging and impactful. It does seem apparent, though, that there are multiple areas of our healthcare system in need of reform and systemic change.
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