Inadequate Prenatal Care and Adverse Environmental Health Exposures in U.S. Carceral Facilities
By Teresa Durham
Since the 1970’s the number of incarcerated individuals in the United States has skyrocketed. Women are the fastestgrowingpopulation in U.S. prisons and jails, underlined by a 742% increase between 1980 and 2016. Three-fourths of incarcerated women are of reproductive age (18-44 years), and some studies have estimated nearly 60,000 pregnant women are incarcerated in the U.S. each year. Despite such growing numbers, there is a dearth of research characterizing pregnancy within the country’s carceral system, including documentation of prenatal care and analysis of the heightened vulnerabilities of being pregnant while incarcerated. From what we do know, there is much cause for concern regarding inadequate prenatal-health care provided in carceral facilities as well as a range of harmful environmental conditions faced by pregnant women in prisons and jails.
The 1976 Supreme Court decision of Estelle v Gamble established that the deliberate failure of prison authorities to address the medical needs of an incarcerated person constitutes "cruel and unusual punishment". In accordance with the Eighth Amendment, it emphasized that the “deliberate indifference to serious medical needs of prisoners constitutes the 'unnecessary and wanton infliction of pain’”.
Unfortunately, this attempt at protection has proven to be grossly insufficient, as the health of pregnant incarcerated individuals across the U.S. remains routinely compromised by inadequate access to prenatal care, poor nutrition, lack of mental health services, and under treatment of sexually transmitted infections, all of which can adversely impact both mother and developing fetus. The language of the 1976 ruling allows for flexible interpretation of “deliberate indifference” and “serious medical needs”, leaving what qualifies as harm to pregnant individuals to be decided at the discretion of individual guards, prison wardens, and ultimately, the courts.
The 1976 Estelle v Gamble decision ostensibly aimed to protect Americans from undue harm and the same can be said of the Thirteenth Amendment. While U.S. history documents an abolition of slavery, decades of astronomical incarceration rates paint a different picture. Because the phrase “except as a punishment for crime” was included in the Thirteenth Amendment, it allowed for the continued subjugation of and institutionalized violence against Black and brown communities.
Further attempts to standardize adequate care have been made by the American Public Health Association (APHA), American College of Obstetricians and Gynecologists (ACOG), and the National Commission on Correctional Health Care (NCCHC). Each has provided prison systems with a framework to supply incarcerated women with suggested prenatal screening tests, special diets, and drug rehabilitation when necessary. Adherence to such standards of care, however, are not required, and given the prioritization of low-cost imprisonment, evidence of these recommendations being implemented is elusive. The jarring shortcomings are highlighted in the National Women’s Law Center’s 2010 analysis highlighting the practices of federal prisons and detention centers across all 50 states, where they indicate that 34 states do not require screening and treatment for women with high-risk pregnancies, and 48 states did not provide pregnant individuals with HIV screenings. More recent data from a study in 2022, pooling from 22 state prisons and 6 jails, including the 5 largest jails in the U.S., found that a third of the prisons and half of the jails did not have accredited healthcare services.
It is important to note that even if prisons exercised a strict fidelity to each of the above guidelines, pregnant incarcerated women, and the developing fetuses, would remain supremely vulnerable simply by virtue of being in prison. Prison populations, which are disproportionately from marginalized backgrounds, find themselves frequent victims of environmental injustice both prior to and during incarceration. Compared to the general population, incarcerated people are disproportionately exposed to harmful environmental insults, including toxic air, water pollution, and extreme heat.
Research has repeatedly shown that poor, Black and brown communities are subject to significantly higher levels of environmental toxicants than their wealthy, white counterparts, a discrepancy that manifests in a range of disproportionate health outcomes. Due to lower costs of unwanted land, the U.S. has a history of constructing prisons on or near landfills and coal ash sites, evidenced by the notorious Rikers Island in New York City and now closed Northwest Detention Center in Washington state. Exposure to harmful toxicants released by waste sites, namely the endocrine disrupting particulate matter 2.5 (PM2.5), is inextricably linked to poor health outcomes, including cardiovascular disease, neurological damage, birth defects, and heritable genetic alterations.
Furthermore, the highly dense nature of prisons, combined with little or no air conditioning, poor ventilation, and minimal windows strongly contribute to an overall reduction in air quality. Not only does this render individuals more susceptible to pollutants originating from outside the walls of the carceral facility, but it also allows for the sustained harboring of disease within them. Prison populations are historically at higher risk of contracting harmful infectious diseases like tuberculosis, COVID-19, syphilis, and HIV.
For pregnant incarcerated individuals, the risk may be even greater. Physiological changes that occur in pregnancy, including shifts to the immune system and oxidative stress defense system, can leave pregnant inmates uniquely vulnerable. Deficient prenatal care with inconsistent infectious disease screenings, as well as senseless economic barriers like co-payments for doctor’s visits and basic hygiene materials, further increase the possibility that diseases progress untreated. The consequences of conditions like syphilis and HIV going untreated during pregnancy are not only devastating for the mother, but if passed to the fetus in utero can lead to severe, lifelong disadvantages and even fetal demise.
It is known that pregnancies among women who are incarcerated are often high risk and frequently complicated by increased stress, suboptimal nutrition, and inadequate prenatal care. Additionally, pregnant incarcerated individuals exhibit higher rates of exposure to environmental health hazards, ranging from poor air quality to disastrous spread of infectious disease. However, if such harmful conditions are allowed to persist so long as parties in power can prove they are not “deliberate”, then the law offers pregnant women in prison scarce protection.
In theory, the two ways to prevent undue harm to pregnant women in prison are to either reimagine and reconstruct carceral facilities or question whether people should be incarcerated in the first place. In practice, many permutations of the former method, “healthier” prisons, have been attempted, yet unsafe jail and prison conditions remain largely unchanged. For the sake of equitable reproductive health, an entirely new alternative must be considered.
