Reproductive Justice, Unshackled

For the approximately 1400 pregnant people in U.S. federal and state prisons ¹  and close to 55,000 people who cycle in and out of U.S. jails each year, about 753 people give birth while in carceral custody and only around 1% of these pregnancies end in abortion. ²  Regardless of the outcome of the pregnancy, the common denominator among all these scenarios is that prisons, jails, and detention centers are sites of reproductive injustice.

An older Department of Justice report found that 54% of pregnant people in state prisons reported experiencing no prenatal care, according to research published in Jailcare: Finding the Safety Net for Women Behind Bars by Carolyn Sufrin, MD, PhD, founder of Advocacy and Research on Reproductive Wellness of Incarcerated People ( ARRWIP ). ³  People in carceral custody might be shackled in certain instances during pregnancy, labor, and birth, even though 40 states and Washington, D.C. have passed a law prohibiting shackling during labor and delivery as of 2022—15 of those states also restrict shackling during pregnancy, labor, birth, postpartum, and during medical transportation. ⁴  It is also possible that incarcerated people do not want to be pregnant in the first place, but due to lack of access to contraception or enough resources for abortion care in carceral custody, have no choice but to continue with the pregnancy.

Doula care is one potential solution in situations where reproductive justice is so starkly disregarded, to work as advocates for incarcerated people across the reproductive spectrum, ensuring they have access to contraception, abortion resources, pregnancy education, nutrition, and care, labor and birthing support, and postpartum emotional support. But there is more to the story: New parents are separated from their infants upon returning to a carceral facility and often are located hundreds or miles from family members who are appointed as caregivers of the newborn. On top of that, doulas may be working on a volunteer basis and have to drive long distances to arrive at the hospital where the incarcerated person is giving birth. To capture the full scope of doula work, this project maps both the nuanced aspects of doula projects in carceral systems and the locations of the facilities in which they practice.

A  2020 study  with a small sample size found that doula support for pregnant and birthing incarcerated people did not necessarily have an effect on certain birth outcomes, such as NICU admissions or birth weight, as compared to incarcerated people who in the past did not have the same support. Regardless of those specific factors in a small study, doulas can only have a positive influence on pregnancy, birth, and postpartum. The study was not able to record maternal satisfaction, time with their infants, or the patients' feelings of autonomy, so there is still an incomplete empirical picture of just how beneficial doula programs can be for the well-being of incarcerated people with uteruses. ⁵ 

While it would be ideal to have doula projects in every carceral setting in the U.S., the reality is that getting into the prisons, jails, and detention centers, securing funding, and continuing programming in the facility with support from staff or other state institutions is the real challenge. Sometimes, the detention center is located so far away from a major city that traveling to get quality health care outside the facility and having enough doulas—some of whom may be volunteers—is not going to be possible. Other times, there are barriers in the prison itself keeping doula projects from flourishing and from following birthing people's cases after they have children, get separated from those children, and need additional mental health care; the new caregivers of the separated children also may need financial and emotional assistance.

The primary constraint for most prison doula projects is budgeting, and with that proving the inherent value of doula work to prison staff, state officials, foundations, and independent donors. Many projects operate on a volunteer basis, which can make burnout and losing volunteers a regular occurrence. The  University of New Mexico Health Birth Companion Program  works with volunteers to provide no-cost support to uninsured, teen, undocumented, and incarcerated patients giving birth at the University of New Mexico Hospital in Albuquerque, New Mexico, many of whom would otherwise be birthing alone. The volunteer doulas are called to the hospital when a patient arrives on the labor and delivery floor, so they often have no prior interactions with the birthing person, and are not able to stay much longer than a few hours after the birth to assist with the inevitable separation of parent and child about 24 hours later, according to one of the volunteers affiliated with the birth companion program. Prison guards who accompany the incarcerated person from either the state prison in Grants, New Mexico or the county detention center in Albuquerque are sometimes reluctant to let volunteers in the delivery room—though they are not providing any birthing support themselves, so the program volunteers insist on being present.  

Gatekeeping by employees of the Department of Corrections or any other prison officials also happens frequently and can prevent doula project longevity. The  Minnesota Prison Doula Project  attempts to uphold an amicable rapport with prison staff so that they can continue their programming, including pregnancy and abortion support, parenting counseling, and labor and delivery support. “But I think more than all of that [barriers to finding and sustaining funding] is getting in the facilities and staying in, with the constant agitation of the system that you know is broken, but just enough to stay in the door,” a partner of the program shares. Continuing funding streams also proves difficult when the majority of people who are incarcerated in the U.S. are people who cannot get pregnant—consequently, this work is not prioritized. After beginning the program in Minnesota’s Shakopee Correctional Facility over ten years ago, the team was whipping up baked goods themselves and holding bake sales in order to stay afloat and be able to fairly compensate the doulas for all their labor, the program partner explains.  “Our doulas are on call 24 hours waiting for their clients to go into labor and may have to drive in a snowstorm to get to the hospital and then witness the horrifying separation of biological and their babies. That is hard emotional work, taking them away from their own children and families, and it should be compensated,” the MPDP partner adds. 

While some reproductive care that incarcerated people receive is abysmal—no prenatal dietary consideration, access to the contraception they had pre-incarceration, and no pregnancy or postpartum-specific education— other facilities are an exception and offer more comprehensive care. Cook County Jail in Chicago is one such facility: “The jail doesn’t outsource care to a for-profit corporation. Providers who do healthcare onsite are members of the medical staff at Cook County Hospital...If people need any other services that can’t be offered on site, they go to the main Cook County hospital,” explains one of the founding members of the organization  Illinois Birth Justice .

Illinois is specifically known as a mecca for reproductive justice, as it was the first state to ban shackling during labor and birth and expand Medicaid for postpartum care coverage up to a year after birth. Additionally, anyone in the Cook County Jail who requested abortion services was able to get them, the collective member notes. The doula program run by Illinois Birth Justice provided pregnancy and birth support directly in the jail until the COVID-19 pandemic hit in 2020, and then advocated for the release of incarcerated people in their third trimester for home monitoring. Because jail involves a sentence that is typically under a year, it is the healthiest option for pregnant people to serve the rest of the that time at home. There are more birthing people in county jails for minor charges than in federal custody anyway, adds the Illinois Birth Justice member.

Cook County Jail also has somewhat rare backing from the county sheriff’s office; one employee of the office shares that they personally advocate for the expansion of doula access in carceral settings, specifically in county jails. “It can be so impactful to have a holistic resource by your side during that time. And in a few cases, I go so far as to say the doula relationship has been vital to the woman’s success in getting situated at home and not returning to custody,” the employee states. A survey of corrections officers also reported they supported prison doula programs overall; however, 84% of those corrections officers surveyed also claimed that the health care for incarcerated pregnant people was just as comprehensive as care for non-incarcerated pregnant people. ⁶  Though doula networks technically exist outside the state and the medical industrial complex, sustaining support from state agencies is often one of the only ways prison doula programs can survive.

 Doula projects run into issues when they want to prioritize working with people who are justice-impacted themselves and may have the greatest ability to relate to people who are currently incarcerated. It is difficult to build your own doula business upon release and to be able to live on those wages. Not only that, but prisons do not let formerly incarcerated people into the facilities to work with currently incarcerated people for security purposes, states a staff member of the New York City-based organization  The Ladies of Hope Ministries  who was formerly incarcerated and experienced doula care during pregnancy upon release from custody. That is one of the reasons that The Ladies of Hope Ministries is leading virtual trauma-informed doula training for formerly and currently incarcerated people to assist people who are pregnant and postpartum in prisons and jails and in other birthing settings. Because The LOHM staffer did not receive any assistance during pregnancy in custody, and encountered doula support in the form of prenatal yoga and childbirth classes afterward through a program for low-income people, it was all the more important to make sure justice-impacted pregnant people could access doula services: “That was the only time I was celebrated as a pregnant person, as a mother, as a person, and actually, I believe it was almost life-saving because I was in such a deep depression from it.”

Supplying culturally sensitive care that takes the incarcerated person's identity, mental health, and trauma history into account is a key piece of doula projects’ work. So much of birth work is led by white-presenting people. However, “Black women are two and a half times more likely to be represented in the prison system. And so when we're talking to people, they need to feel comfortable divulging information about what their family needs. They don't want to feel like they are exposing their family to more harm, especially when so much is out of their control while they're on the inside,” explains a doula with  Genesis Birth Services’ PRISM Project  involved with the State Correctional Institution at Muncy in Pennsylvania. The program provides everything from prenatal and childbirth education, hospital birthing support, a year of postpartum support, lactation and feeding support for parents, and education for caregivers and family who have custody of the infants. They can even assist those caregivers with finding housing and do home visits, but families need to feel comfortable accepting these services from people they feel they can trust. “This is where you have to understand the demographic of people you’re working with,” the PRISM Project doula adds.

Many other projects are not able to offer the degree of postpartum support that Genesis Birth Services does, but this is crucial to following incarcerated people and their needs throughout the reproductive spectrum. It is especially dire given that postpartum mental health care and evaluations are rare in prisons, and alerting corrections officers of a postpartum mental health concern could result in the person being put in solitary confinement, which is objectively a worse situation for mental health, according to the Minnesota Prison Doula Project Partner. Genesis Birth Services pushed back against the state of Pennsylvania, which only wanted to offer birth support as part of the state-funded prison doula program, to offer more full-spectrum care. “You can’t expect good maternal health outcomes if you just attend the birth,” the doula affiliated with the program says.

  Motherhood Beyond Bars  is another organization that also focuses on support for caregivers of new babies and people leaving incarceration and on probation. Now a 501c3 organization, at one point they were working on a volunteer basis, providing birth support, prenatal yoga, and baby showers to incarcerated pregnant people in the Georgia Department of Corrections, many of whom are transported to Helms Facility in Atlanta during their pregnancy. But Motherhood Beyond Bars pivoted their work in 2019 largely due to lack of support from the Georgia Department of Corrections. The organization's members kept returning to what incarcerated people shared as their biggest needs: someone to help take care of their babies and the babies’ temporary caregivers, and help reuniting with their children and families upon release. In 2020, MBB launched a program that gives family caregivers a lifetime supply of diapers and other basic necessities, sets them up with food, counseling, and free daycare through a program called Head Start and supports the reuniting of parents with their children upon release by keeping in touch with the incarcerated parents while they are in carceral custody. Though they are not able to work inside the prisons in Georgia, they are able to facilitate the often neglected work of reentry support and care for caregivers, who are now the de facto parents of the new baby. Dr. Carolyn Sufrin’s article, “Making Mothers in Jail: Carceral Reproduction of Normative Motherhood,” compares incarcerated parents who cannot then raise their children to “gestational carriers.” “Women who are disproportionately women of color and women whose lives are affected by economic insecurity are conscripted into a non-consensual arrangement that entices them with motherhood, only to lead their children to other parents through the surveillance and control of carcerality.” ⁷ 

Things in Georgia are additionally complicated from a reproductive justice lens, with a six-week abortion ban.  Some people in carceral settings seek abortions because of lack of financial stability or not wanting to experience pregnancy in such a hostile environment. However, carceral facilities do not make it easy to access contraception or abortion—often incarcerated people have to pay for the procedure itself, which is not something they can typically afford without health insurance or the Medicaid access that they lose upon entering custody. ⁸ 

The staff member at Motherhood Beyond Bars notes that this issue has come up particularly on the reentry side: One of the people they were counseling recently was pregnant and was seeking an abortion. The person was on probation, so they could not leave the state without violating probation, and therefore were not able to access an abortion since they were past six weeks of pregnancy. “We haven’t even seen the tip of the iceberg of this. Most of the people we talk to do want to be pregnant, but the day we get a person in our childbirth education class who is there because they tried to access abortion will be a very difficult day,” the Motherhood Beyond Bars staffer shares. And post Dobbs v. Jackson, there could be even more pregnant people who end up in carceral facilities, the Minnesota Prison Doula Project partner says—which makes some kind of reproductive justice intervention, such as doula care, even more critical.