Birth Behind Bars: The Difference Trauma-informed Doula Care Can Make

Editor’s note: This article first appeared in Midwifery Today, Issue 130, Summer 2019.
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I loved being pregnant. When I think back on my own pregnancies, the emotions that predominate are excitement, contentment, and happiness. In my rosy memories, I spent a lot of time relaxing in a warm bath while watching the ripples of fetal movement in my growing belly. Even so, there were times when pregnancy was less than pleasant for me. Times when I felt sick or exhausted or weary of trudging my way through another day of 90-degree heat, waiting for an August birth that it seemed would never happen. Times when I couldn’t get comfortable in bed but dreaded the effort of rolling over onto my other side. Times when I was tired of shuffling to the bathroom to empty my bladder yet again.

I can only imagine what it would be like to endure a pregnancy without the ability to decide when and what I would eat, without the freedom to choose who would attend my birth or when the time was right to call them, without even the freedom to grab an extra pillow to cushion my body at night.

Every year in this country at least 10,000 women spend some part of their pregnancies in jail or prison, and at least 2000 give birth while incarcerated (Sufrin 2017). Precise figures don’t exist, partly because these women are scattered throughout a diverse set of federal, state, and county facilities, and partly because few people have cared enough to study this population or attempt to advocate for them.

The United States not only has the largest prison population in the world, we have the world’s highest per capita incarceration rates, and women represent the fastest-growing segment of the prison population. In recent decades, the number of women behind bars at any given time has increased by more than 500%, mostly because of the War on Drugs, mandatory minimum sentencing, and a more punitive orientation in our justice system (Sufrin 2017). And, more so than for men, when women are incarcerated, families are disrupted and often splintered. Two-thirds of the female prison population have children. And while 90% of incarcerated fathers know that their kids are being cared for by the biological mother, only 28% of incarcerated mothers are able to leave their kids with the children’s father (Hotelling 2008).

These women end up behind bars for as many reasons as there are incarcerated women. Each individual has her own story. But they often share a set of common circumstances, including a history of abuse, neglect, family violence, and a high rate of exposure to community violence. “Women’s pathways to prison are filled with trauma,” states Rebecca Shlafer, a developmental psychologist and assistant professor of pediatrics and adolescent health at the University of Minnesota. Shlafer heads a research team that is studying the effects of incarceration on families and is specifically collecting data on the Minnesota Prison Doula Project.

The Minnesota Prison Doula Project strives to provide doula support as well as prenatal and parenting education for incarcerated women in Minnesota’s only state women’s prison and in the state’s county correctional facilities. Shlafer is documenting the outcomes of the program’s participants. It makes intuitive sense that prison doula programs are worthwhile, and those who work with the program have heard from clients that they are life-changing, but having data to back up anecdotal evidence will make it easier to launch similar programs in other states. “I’d like to make a case that this matters,” Shlafer says.

Other prison doula projects around the country are in varying stages of development. The Michigan Prison Doula Initiative, spearheaded by Jacqueline Williams, currently provides childbirth education and, in late February 2019, they received state approval to provide doula services. They are now hoping to attend births as soon as April 2019. The Alabama Prison Birth Project, under the leadership of executive director Ashley Lovell, began conducting childbirth classes in 2016 and first matched doulas with moms early in 2018. They have now passed the milestone of their 25th birth with doula support. The Prison Birth Project operated in western Massachusetts for a full decade and provided trauma-informed doula care for over 300 women, before it ceased in 2018 due to a lack of support and funding. Support and money are not the only challenges prison doula projects face, but they are formidable ones that are shared by the handful of other programs that are scattered around the nation.

Vicki Elson served for four years as a childbirth educator and doula with the Prison Birth Project in Massachusetts. She viewed her work with the women as an opportunity for transformation and a pathway to healing. She states that her clients at the prison were, without exception, “survivors of trauma—a lot of sexual trauma, plus physical, economic, and other kinds of trauma.”

Jacqueline Williams, of the Michigan program, believes that most of the women she seeks to help come from backgrounds shaped by poverty, addiction, and violence. “Most female inmates are addicts, not axe murderers, yet the system treats them all as if they’re axe murderers.”

Indeed, this country’s prison system was designed by men for a male population. The female demographics are significantly different. The majority of incarcerated women are first-time offenders who are there for non-violent property offenses or crimes involving drugs. Most female inmates are in their childbearing years, with a median age of 34, and anywhere from 4 to 6% are pregnant when they enter the system (Clarke and Simon 2013). Once there, they must find their way through a set of protocols designed for violent men, not for pregnant women who are themselves abuse survivors.

Because male prisoners can pose a flight risk when being transported out of the facility to see a doctor, and thus may be shackled for the trip and during the appointment, women are sometimes shackled as well. Some women have been shackled, with metal leg irons, during labor and delivery, even though an armed guard is stationed at the door of the hospital room, and even though there are no recorded cases of a woman attempting escape around the time of birth, and even after medical personnel have asked for removal of the shackles.

Both houses of Congress have seen bills introduced in the past two years aimed at improving conditions for incarcerated women. Both the Senate’s Dignity for Incarcerated Women Act and the House’s Pregnant Women in Custody Act are currently stalled in committee. The First Step Act, passed in December of 2018, seeks to reform federal facilities, and it prohibits the shackling of pregnant women.

Although the treatment of women in state and county facilities hasn’t yet been addressed by comprehensive legislation, the use of shackles, including leg irons, on a woman in late pregnancy is such a disturbing image that over 20 states have passed legislation banning or restricting the practice. But these restrictions are often ignored. Illinois was the first state to ban shackling, but the practice continued in Chicago at the Cook County Jail for years. The jail eventually paid $4.1 million total to almost 80 plaintiffs in a class action lawsuit. Those women were chained—wrist and ankle—to their beds during labor in the years between 2007 and 2010, after shackling was illegal (Huffpost 2012). Some states have no laws on the books that address the issue. The American Medical Association calls shackling a woman during childbirth “barbaric,” the American College of Obstetricians and Gynecologists states that the practice is “demeaning and unnecessary,” and Amnesty International deems it a violation of international human rights. Yet the practice continues (Nelson 2017).

A woman who gives birth behind bars contends with a host of other challenges, as well. She has little to no control over her diet, her clothing, or basic comfort measures. A bra that fits, a nutritious snack, an extra pillow: none of these are within her control. She may not even be told her due date, in case family members might use that information to help her plan an escape attempt. When labor begins she has to convince the staff on duty at her facility that it’s the real thing; she receives care at their discretion. Her family will be notified that she’s in labor when prison staff get around to it, and if any loved ones do manage to meet her at the hospital they can have no physical contact. In Alabama where Ashley Lovell works, the woman’s family members and partner cannot be present for the birth. Female inmates labor in a room filled with strangers—nurses, a doctor, an anesthesiologist, possibly an intern—and two security guards at the door. “If we weren’t there, no one would be there to hold her hand. That’s the biggest need,” says Ashley. Jacqueline Williams of Michigan also believes that the presence of labor support shows these women that “the world outside still cares.”

Doulas who work with incarcerated women do the same things that doulas do for women on the outside, with some significant differences. The Prison Birth Project in Massachusetts developed their own doula training with a curriculum that covered topics most doulas seldom face: jail policies, stigma, substance abuse, sexual assault, PTSD, and parental rights (Prison Birth Project 2018). When working with women on the inside, listening can be more important than giving advice. “I found most incarcerated mothers to be so receptive to a little bit of love,” states Vicki Elson, adding that one of her prison doula clients called her seven years later. She was having another baby, on the outside, and wanted Vicki to be there for her again.

One of a prison doula’s most important roles is to help a mother prepare for separation from her baby. That impending separation can overshadow everything else, because the mother knows that she will have only a few hours, a few days at most, before she must relinquish her baby. Only a handful of states have prison nurseries where female inmates can care for their babies themselves, so most are sent to a family member on the outside, or enter the foster system. The separation is the hardest part of the experience, and doulas try to be there at that time to support the mother. Prison doulas encourage as much mother-baby bonding as possible, including breastfeeding and skin-to-skin contact. “It is not easy to hold your baby and then let go 24 hours later,” Ashley Lovell says, “but I tell moms they will want to look back and know they did everything they could. No mother regrets skin-to-skin contact. But we don’t judge her if she chooses not to. We haven’t walked in her shoes.”

Labor itself can be hard for incarcerated women to navigate because it begins a woman’s process of separation from her baby. For some women, their water breaking can trigger a strong emotional response because it means there’s no turning back. And it can be difficult emotionally for women with a history of IV drug use to have a vein accessed. The doula can be a constant presence, someone focused on the woman, and able to tell her, “I’m here with you.”

Sometimes hospital staff have prejudices or fears that lead them to stigmatize inmates. Other times hospital personnel may strive for impartiality and compassion, but aren’t aware of the triggers that can affect incarcerated women. When the hospital staff are uncomfortable, doulas can help them see the women in their care as human. And the doula can advocate for women’s needs. In the words of a doula with the Prison Birth Project in Massachusetts: “I have stood in labor rooms and watched the pushback when pregnant people have asked for their needs to be met, needs which non-incarcerated pregnant people would not even need to ask for.”

Prison doulas can bring a focus and a sensitivity to their role that others serving in the hospital might miss. Beyond simply being there with the women, whose biggest fear is often giving birth among only strangers, the greatest service doulas can provide for incarcerated women might be nutritious food. Ashley Lovell always brings food to the childbirth classes she teaches inside Tutwiler Prison in Alabama. She says some of the women begin attending initially just to eat. “At least one of her meals that week is packed full of protein, omega-3s and folic acid,” Ashley says.

Vicki Elson also brought healthy food, full of fiber, to her childbirth classes in Massachusetts, whenever prison staff didn’t prevent it. “Prison food is usually beige in color,” according to Vicki. “Potatoes, cheese, bread. It’s a constipating diet. But instead of giving the women more fiber, they just give them laxatives.”

In the eyes of many people, these women don’t deserve nutritious food, adequate care, or compassion. Or at least many people don’t see providing for these women’s needs as a priority. After all, they landed where they are as the result of choices they made. Except that many of them, who grew up amid abuse themselves, never had much of a chance to make positive choices. The majority are behind bars for drug offenses. Some turned to drug use to cope with difficult circumstances. Some were in relationships with partners who trafficked in drugs, but they were the ones who got caught. And the babies are certainly innocent and deserve the best relationship they can have with their mothers. When those mothers are treated with compassion and support, we all benefit. The babies are more likely to be healthy, resulting in lower medical costs.  

Over 80% of women who give birth while incarcerated will be released within two years (Alabama Prison Birth Project 2019). Once on the outside, they become our neighbors once again and need to reconnect with their children at that point. Better bonding and better parenting mean less recidivism. While 300 women is a statistically small sample size, it is significant that of those women for whom the Prison Birth Project in Massachusetts provided care and who were subsequently released, only one has ended up back inside. It seems the program truly did reduce recidivism rates (Bullock
and Elson 2013). Erika Arthur, who served on the Leadership Circle for the Massachusetts program, stated: “[F]inding people in those moments and helping transform their experience from one of trauma to one of support in a dark time is so incredibly powerful.”

Doula care can make a bigger difference for incarcerated women than for perhaps any other population. For women who’ve suffered repeated trauma and deprivation, pregnancy can be a chance to start over—a rebirth for the mother herself. And for women who have never been treated with the unconditional and non-judgmental compassion that doulas provide, the right kind of support can truly make birth a life-changing event. Part of a doula’s role has been described as “mothering the mother”; some women have never been on the receiving end of that kind of care and a doula’s concern can be a real turning point that re-directs what may have been a generational cycle. A woman who was served by the Prison Birth Project in Massachusetts said, “I’ve struggled knowing what love was my entire life.”

These women have experienced tremendous pain and loss; to have a doula walk with them, even for a short time, can matter intensely. In the words of Jacqueline Williams: “When we reclaim humanity at this level, it reverberates down generations.”

  • Alabama Prison Birth Project. “Frequently Asked Questions.” Accessed March 5, 2019.
  • Bullock, Marianne, and Vicki Elson. “Doulas Working in Prisons.” The Doula Guide (blog). April 24, 2013.
  • Clarke, JG, and RE Simon. 2013. “Shackling and Separation: Motherhood in Prison.” Virtual Mentor 15(9): 779–85.
  • Hotelling, BA. 2008. “Perinatal Needs of Pregnant, Incarcerated Women.” J Perinat Educ 17(2): 37–44. doi: 10.1624/105812408X298372.
  • Huffpost. 2012. “Pregnant Cook County Jail Inmates Win Settlement in Class Action Lawsuit.” Accessed March 14, 2019.
  • Nelson, Rebecca. 2017. “She Knew She’d Deliver Her Son While She Was in Jail. She Didn’t Expect To Do It in Chains” Cosmopolitan. Accessed March 5, 2019.
  • Prison Birth Project. 2018. “Celebrating 10 Years of Reproductive Justice.” Legacy Report 2008–2017.
  • Sufrin, Carolyn. 2017. Jailcare: Finding the Safety Net for Women Behind Bars. Oakland: University of California Press.

About Author: Mary Ann Lieser

Mary Ann Lieser is a freelance writer and doula, and sells used books in Wooster, Ohio. She is the mother of eight homebirthed children.

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