Using restraints on female inmates who are pregnant, in labor or have just delivered a baby sounds like a practice from the Middle Ages, yet it is occurring today nationwide. Thirteen states have no policy forbidding the practice. Even in states that limit it, police officers, corrections officers and those who transport prisoners still handcuff, shackle or otherwise restrain these inmates, in part because they don't understand their states' policies.
In general, police officers and others use such restraints on prisoners to prevent individuals from fleeing or fighting. Handcuffing or shackling may occur when officers feel threatened, when prisoners are being transported from one facility to another, or for a variety of reasons when prisoners are in custody.
For most female and pregnant inmates, however, the practice defies logic. Statistically speaking, most female inmates are not violent offenders, so restraining them to prevent attacks on workers is largely unnecessary. Pregnant women are also unlikely to pose a flight risk. But most important, shackling — which can include the use of handcuffs, waist chains or leg irons — poses serious health risks for the woman and the fetus. These include a higher risk for falls, problems related to those falls, and barriers to providers' ability to detect and treat pregnancy-related complications such as pre-term labor and hemorrhaging during delivery and after birth. And, restraining new mothers can prevent them from holding and bonding with their babies, according to the American College of Obstetricians and Gynecologists, or ACOG.
What's more, these risks are being taken with a population that has a higher-than-average rate of mental health problems, including post-traumatic stress disorder, depression and substance abuse.
In the past few years, psychologists and providers who work with female inmates have started to document the use of such restraints and advocate that they be banned or limited only to cases of absolute necessity. In tandem with these efforts, APA is working at the federal level to educate policymakers about the issue and to contribute research-related information to legislation aimed at prison reform. In addition, psychologists are working to pass, or have already helped to pass, anti-shackling legislation in states including Minnesota and Virginia.
"The national focus on criminal justice reform provides a great opportunity to raise the profile on this issue with the public and policymakers," says Micah Haskell-Hoehl, APA senior policy associate. "People who didn't know about the practice can't believe it still happens."
By putting a spotlight on the issue, psychologists also hope to illuminate the importance of better understanding and addressing the needs of female inmates in general, says Amalia Corby-Edwards, an APA senior legislative and federal affairs officer.
"We are using [shackling] as a wedge to open up a larger conversation about gender-responsive justice systems more generally and to help us consider what psychology can do to encourage better health and mental health care practices for women in the criminal justice system," she says.
Why is it happening?
Restraining pregnant inmates is a result of prisons and jails failing to update existing policies to accommodate women, who now make up about 10 percent of the prison population, says University of Minnesota assistant professor Rebecca Shlafer, PhD, who is studying the mental and physical outcomes of a support program for pregnant inmates in Minnesota.
Better understanding of the issue also has been hobbled by a lack of data, she and others say. The federal government does not require prisons or jails to collect data on pregnancy and childbirth among female inmates. As a consequence, data are incomplete, uncoordinated or nonexistent. At the same time, the issue is gaining public traction due to rising female incarceration rates, greater knowledge about the effects of incarceration on children and families, and the unique considerations of incarcerated women.
The evidence that does exist suggests incarcerated women are not getting the care and treatment they need. Danielle Dallaire, PhD, of the College of William and Mary, who heads a healthy nutrition program for pregnant and postpartum women in several Virginia jails, first heard about the shackling issue from incarcerated pregnant women there. In an unpublished survey, she found that a third of women who gave birth while incarcerated reported being restrained during delivery.
Dallaire also found that the women who were shackled were significantly less likely to initiate breastfeeding after the child was born than those who weren't put in restraints.
"Shackling does seem to impede infant-mother bonding," she says.
Dallaire also is examining health-care practices in general for pregnant women in jails. In the first national study to look at this population, currently under review, she and colleagues found that most jails fail to follow national guidelines for incarcerated pregnant women promulgated by groups including ACOG. For example:
- Fewer than half of the 53 jails surveyed reported giving pregnancy tests to all women who enter the facility, and less than half provided fluid supplements or healthy food options for pregnant women.
- Nearly half of the jails reported that pregnant inmates addicted to opioids when they entered the facility went through withdrawal with no medical assistance.
- More than 17 percent of the jails required that women be handcuffed or shackled during and after delivery, and more than half of them restrained women immediately after delivery.
Those findings square with a national survey of 19 state prisons conducted by Ginette G. Ferszt, PhD, and Jennifer Clarke, MD, and reported in the May 2012 issue of the Journal of Health Care for the Poor and Underservedopens in new window. The team found that many state prisons fail to meet nutritional recommendations for healthy pregnancies, that many pregnant inmates don't get adequate rest, and that psychosocial support and education are minimal at best. Restraints were used "as a matter of procedure in many facilities, even during labor and delivery," the study also notes.
Advocacy, policy and education
APA and psychologists are using this and related information to educate policymakers and others with an eye toward reform. In Minnesota, for example, Shlafer played a key role in urging the state to adopt a comprehensive bill that not only limits the use of restraints for pregnant women in custody, but provides them with mandatory birth support and pregnancy testing. Passed unanimously by the state House and Senate in 2014, the bill also created a legislative advisory committee of representatives from corrections, public health and human services now headed by Shlafer. The group meets regularly to talk about how to balance the women's needs and safety concerns and determine ways to implement the new policies.
On the federal level, APA has crafted a fact sheet and joint policy statement with ACOG, the American Jail Association, the National Commission on Correctional Health Care and several other organizations calling on the federal government to provide for data collection, training and technical assistance and leadership on the issue of incarcerated pregnant women and shackling. The statement also asks for federal policies that would require standardized pregnancy care and evidence- and trauma-informed physical and mental health services for incarcerated pregnant women.
The APA team also worked with Reps. Katherine Marlea Clark (D-Mass.) and Karen Bass (D-Calif.) and House Judiciary Committee staff to usher related language into a prison reform bill, H.R. 759, passed by the House Judiciary Committee Feb. 11. To keep up the momentum, APA also worked to ensure that similar Senate legislation included provisions on restraints, and participants in APA's annual Leadership Institute for Women in Psychology visited Capitol Hill in March to discuss the issue further.
Besides educating policymakers, a major issue to emerge from this work is the need to educate and train corrections workers and providers. As a step in that direction, Shlafer's committee wrote a pregnancy resource guide that is being distributed to all correctional facilities in Minnesota. She and colleagues also are providing trainings for jail nurses, correctional health-care providers, jail administrators and others.
While these efforts are in the beginning stages, Shlafer and others are seeing hopeful signs. On its own volition, for example, the Minnesota Department of Corrections created its own pregnant offender committee. Based on data from Shlafer's committee, the state now allows post-term women throughout the state to pump and maintain their breast-milk supply so they can continue breastfeeding when they return home.
"To me that's a huge win, and not one that our committee set out to see happen," says Shlafer. "But it's a place where we've seen awareness and education and information help leverage the system to change."
