Birth behind bars

Thousands of pregnant people are admitted to U.S. jails and prisons every year—what happens when they give birth?


The father of her unborn baby had just been shot to death in North Boulder. Madison (a pseudonym for the purpose of this article) was there when it happened. She was five months pregnant. And when the police arrived, she was arrested and booked into Boulder County Jail (BCJ) and charged with accessory to murder. She’d be sentenced to two years probation and a year of work release, though the accessory charges were later dropped. 

But before Madison was released back into the community to serve her time, while she was still incarcerated at BCJ, she went into labor. She was taken to Boulder Community Hospital and gave birth to a healthy baby. To this day she struggles to describe the overwhelming love she felt for that child in those precious postpartum moments. 

Within 48 hours, a caseworker with the Colorado Department of Human Services (CDHS) walked into Madison’s guarded hospital room to inform her that they had to take the newborn away. 

“It’s just very horrific,” Madison says. “It was just one of the worst moments of my life when these people came in here, telling me that they’re going to take my child.”

Post-birth bonding builds trust in newborns and sets them up to have healthy relationships throughout their lives, according to UC Davis Health. But Colorado isn’t one of the 11 states that allows for nursery programs or “mother-baby units” in jails and prisons; so when Madison and her baby were deemed fit for discharge, they had to go their separate ways.  

And with Madison in jail, the father dead, and no relatives on either side capable of caring for the infant, her newborn child was placed in foster care with a Boulder County couple. 

That was in 2016. Madison had a handful of visits with her baby early in the child’s life; she missed one, she says, because she lived in the mountains and got snowed in, and missed others because medication she’d been on had made her ill. But she says, the visits she made were very special for her. 

Then, just a month into her work release, while still on probation, she fled the state. 

“The writing was on the wall . . . they were just going to over-prosecute me until I never got out,” she says. “So I left the jurisdiction and I came [to California].”

Her baby was adopted by the foster family she’d been placed with. And today, six years later, that child is still living in Boulder County. 

This is just one complicated case among thousands like it that happen every year in the U.S., according to Dr. Carolyn Sufrin with Johns Hopkins University. It’s estimated that there are more than 58,000 admissions of pregnant people into U.S. jails and prisons every single year. That figure is extrapolated from data Sufrin gathered in a first-of-its-kind study published in the American Journal of Public Health in 2019. 

For her study, “Pregnancy Outcomes in U.S. Prisons, 2016–2017,” Sufrin and several colleagues examined 12 months of data on pregnancies, births, miscarriages, abortions and other outcomes from 22 different prison systems and the Federal Bureau of Prisons. They found that in one year, 1,396 pregnant women were admitted into prisons; 92% of those pregnancies ended in live births, 6% ended in miscarriages and 1% ended in abortions. 

That data wasn’t readily available, Sufrin says. Most prisons and jails don’t keep records on how many incarcerated women are pregnant, how many births happen in any given year or what the outcomes are. They aren’t required to. No federal law or policy requires U.S. jails or prisons to record those numbers, leaving a black hole of information surrounding birth behind bars. 

“Most of the prisons and jails that participated in our study only tracked this information for the purpose of the study,” she says. “Very few actually either were already collecting this [data] or continued collecting it.”

More disturbingly, there isn’t just a lack of information, but a complete lack of any standard of care these institutions are required to provide for pregnant women. 

“There’s no mandatory system of accountability or oversight that makes sure that [prisons and jails are] providing a reasonable level of quality or quantity of health care,” Sufrin says. “So there’s a tendency to sort of marginalize [incarcerated pregnant people’s] healthcare needs. And yet the healthcare needs of pregnant and postpartum people are tremendous.”

Prisons and jails are required by law to provide some level of healthcare to all incarcerated individuals. But there’s no standardized bar for what that should be, resulting in huge variance in the level of care given to pregnant people between jails and prisons in different states, different counties and even within the same county. 

“It’s highly variable when it comes to access to pregnancy care, whether we’re talking about prenatal care, whether we’re talking about mental health care and substance use disorder treatment in pregnancy, whether we’re talking about abortion access, postpartum care or the health care aspects of their birth,” Sufrin says. “All of that varies.”

For pregnant people entering the correctional system, it’s a roll of the dice. Some prisons and jails provide adequate care. Sufrin points to San Francisco’s jail health services, which operates under the umbrella of the San Francisco Department of Public Health (SFDPH). 

“[Incarcerated people] are part of the same system as general health services,” she explains. Meaning they get access to the same healthcare as the general public. There is an experienced women’s health nurse practitioner on staff to provide routine care, and an OB-GYN from University of California San Francisco and San Francisco General Hospital who visits the jails once a week—which was Sufrin’s role for over six years. 

She says, with jail health services under the SFDPH there is “a broader commitment to public health and to recognizing the public health importance of providing healthcare to people in jail.”

Other prisons and jails in other counties and states provide less-than-adequate healthcare for pregnant people—and in some cases even neglect them outright. In 2018, at Denver County Jail (DCJ), a woman named Diana Sanchez gave birth alone in her cell, screaming for help after she’d told both deputies and nurses multiple times throughout the day that she was experiencing contractions and going into labor. The Denver Fire Department arrived 15 minutes after she’d delivered a baby by herself and the firefighters cut the umbilical cord. The entire incident was caught on camera in Sanchez’ cell. 

At Boulder County Jail (BCJ), every arestee has a medical screening within four hours of arrival, assures Melanie Judson, health services administrator at BCJ. They’re asked about medical history, alcohol and drug use, mental health history and pregnancy status. If they believe they’re pregnant, Judson says that leads to a lot more questions: When was their last menstrual period? Have they had any prenatal care? What is their intention with the pregnancy?

“A lot of the time we find out they may not identify [that they’re] pregnant when they come into the jail. They might say, ‘I’m not sure,’ in which case we would do a pregnancy test.” Judson says. “I would say that we usually have at least one, maybe two inmates at a time throughout the year that are pregnant while they’re in custody.”

Once a pregnancy is identified, the jail pulls all of the person’s medical records; finds out if they’ve received prenatal care already and from whom; works with attorneys to find out how long they’ll be in custody, what they’re in for, when their court date is, if they’ve been sentenced, and how long they’ll be at the jail or prison.

If a pregnant person has been sentenced, “We can request from the courts a furlough which would get them out of custody to go back into the community to finish their sentence, either at a later time or to do it at home,” Judson says. And for pregnant people who aren’t sentenced, the jail can request a medical PR bond, allowing non-violent offenders to be bonded out of custody until their court date. 

“Our goal, ideally, if they don’t have to be in jail, is that they shouldn’t be in jail,” Judson says. 

However, sometimes there are no other options. In those cases, when a pregnant person has to remain in custody, they’re immediately scheduled for pregnancy counseling, which is one of Judson’s responsibilities at BCJ.

“I’ll meet with the patient and find out, ‘What is your intention with your pregnancy? Is this a surprise to you? Are you happy about this? Is this a good thing?’” Judson says. “I’ve had females say, ‘I don’t want to be pregnant. I was scheduled to have an abortion before I got stuck in custody, and now I’m going to be forced to have to carry this to term.’ And I’ll say, ‘Well, that doesn’t have to be your option.’” 

Judson says BCJ strives to provide the same healthcare options in custody that her patients would have available to them in the community, including abortion and adoption services. Judson can connect patients who wish to carry the pregnancy to term with prenatal care, either through the patient’s own OB-GYN or with one from the Clinica Family Health People’s Clinic in Boulder. 

“Then I work with the hospital caseworker to identify: What’s going to happen at the hospital?” Judson says. “What’s going to happen with the infant? When will social services become involved? Who’s going to take the infant?”

When the pregnant inmate goes into labor, she’s taken to Boulder Community Hospital and kept under guarded supervision. In 2018, the First Step Act made it illegal to use restraints on pregnant incarcerated people, and at least 29 states have likewise passed laws prohibiting the practice—however, Sufrin says there are a lot of loopholes to those laws. 

“If there’s a significant risk of escape or other exceptions that vary from state to state, then [restraints are] allowable,” she says. “Sometimes the problem is with the hospital staff, frankly, not treating pregnant and birthing people with respect and dignity and according to best clinical and ethical practices.”

Then, the baby is born. And, just like Madison, unless there is some lingering medical reason to keep the mother and baby in the hospital, their time with the infant is usually limited to 48 hours. Sometimes it’s less. 

“They get sent back to jail or prison and they have very limited, if any, in-person contact with their newborn. So it’s really traumatizing,” Sufrin says. “They have no control over the circumstances of their birth or their ability to bond with their babies.”

When the baby is ready to be discharged from the hospital, CDHS needs to have placement lined up, explains Korey Elger, pregnancy manager at CDHS. Elger is an experienced social work specialist, who has seen countless scenarios like Madison’s play out. She says there are a lot of options for mothers before child welfare has to become involved. Ideally, the mother can contact the father and arrange for him to come and pick his baby up. Or, they can arrange for a family member to come and pick the child up. There’s also options for private adoption through a certified agency, in which case child welfare doesn’t ever have to be contacted. Certain states even allow jails and prisons to have nursery programs or mother-baby units that allow for mothers to bring their newborn back to jail or prison with them for a period of time. 

If none of those options are viable, Elger or a caseworker will talk to the mother about alternatives. 

“If we are not able to find any relatives, then we could pursue foster care placement for that child,” Elger says. Adding, “anytime a child is placed in foster care, we’re required to make all reasonable efforts to try and get that child back to their parents, even when they’re incarcerated.”

That means visitation days are federally and statutorily required and scheduled by the state. The Department of Corrections (DOC) and CDHS work together to organize those between the mother and foster family, Elger says. Some jails and prisons have special visitation areas for parents, providing privacy and opportunities for more authentic interactions. 

Even in cases where the mother is handed a prison sentence at an institution a long way from the foster family, DOC and CDHS set up video calls when an in-person visit isn’t an option. 

“Our statutes say we have to do whatever we can to rehabilitate this parent for them to be able to parent,” Elger says. But, “there are timeframes.”

Colorado’s “permanency statute” allows CDHS to allocate parental responsibility, giving some guardianship rights to the foster parents, if an incarcerated parent doesn’t complete their treatment plan in a reasonable time or has an exceptionally long sentence. Or, in more extreme cases, they can terminate the parental rights of the mother, making it possible for the foster parents or another family to adopt the child. 

“That’s not the outcome we want,” Elger says. “We really want families to be reunited when they have their children taken. But unfortunately, there are times where that just can’t happen due to other circumstances.”

Like if a psychologist deems a mother psychologically unfit to care for her child. Or if a mother flees the state while on work release and probation. 

Madison says she’s struggled to maintain a steady job in California because of her criminal history. She has a college degree, she says, but she doesn’t believe she’s ever going to be able to get a job where she can use it. She’s found some minimum wage work, but the risk of being let go is omnipresent should her employer discover her background. And returning to Colorado, where she’s still wanted for failure to comply with the terms and conditions of her work release sentence, is out of the question. 

Nevertheless, Madison says she’s determined to get her child—now six years old—back. Even though that child has lived her entire life with her foster parents. Even though Madison freely admits she’s struggling to hold down work. It’s an all-consuming drive—an obsession—that speaks to the level of trauma she experienced giving birth in the correctional system. 

Sufrin doesn’t know of any silver bullet to prevent the trauma associated with cases like Madison’s. But, she says there are several approaches to preventing it from happening in the first place. 

“We need to have standardization of health care, especially when it comes to reproductive health care, including pregnancy care,” she says. “There needs to be mandatory standards, and mandatory systems of oversight.”

Taking it a step further, Sufrin asks why we’re incarcerating pregnant people at all. Many women (35% or more, according to the ACLU) are incarcerated for non-violent crimes. Non-violent offenders who are also pregnant present a minimal threat to their communities, she argues; these women could easily serve time outside of the jail or prison at least until they give birth. 

“Is prison or jail really the appropriate place for them?” she asks. “We should be investing in alternatives to incarceration and the upstream causes of why [these individuals] are enmeshed in the criminal legal system in the first place—things like structural racism, housing instability, food insecurity, adequate healthcare and substance use treatment. Especially for females.”