Prison Birth Project supports ‘invisible’ population of incarcerated pregnant women in the USA

Ashley never planned to become a doula. She initially studied to become a wildlife biologist and worked in that field until she gave birth to her first child. As a new mother, she was overwhelmed and completely surprised at the difference between her expectations and the reality of having a newborn and she suffered from postpartum depression. While pregnant with her second child she hired a doula to support her during pregnancy and birth, greatly impacting her experience. The support received from her doula helped to instill a strong sense of confidence throughout the birthing process (and postpartum) which she didn’t have during her first pregnancy. She saw the impact of her own postpartum depression on her eldest child, realizing that when a parent is not well herself, it can have a great impact on her child(ren). She suddenly felt an intense desire to become a doula herself to help support mothers during pregnancy and birth. She quit her job as a wildlife biologist and completed her training as a doula, starting her new path as a birth worker in Alabama, USA, where she lived.

She eventually received a request from a nurse at Julia Tutwiler Prison for Women, the maximum-security prison in Alabama for females. Tutwiler was facing a lawsuit over unconstitutional circumstances for the women incarcerated at the facility. The Department of Justice had sued the state of Alabama, resulting in requirements to comply with new regulations to improve the conditions for the female prisoners, such as increasing the number of female officers and offering gender-responsive and trauma-informed care. The nurse asked if she and other community doulas could teach childbirth classes, and the Alabama Prison Birth Project was born.

Ashley never could have imagined that her path would lead her to this type of work, but she was immediately drawn to the cause. “I grew up with a cousin who was incarcerated (in Texas) almost his entire life and watched my mother write letters, call the warden, advocate for him, and visit him. After watching the grief and destruction on his family during his life and while in prison, I started to wonder what life must be like for incarcerated pregnant women.”

Despite recent reforms, the United States still incarcerates 698 people for every 100,000 residents, more than any other country in the world. Compared to that number, the women’s incarceration rate (in the US) of 133 seems quaint. But it’s the highest incarceration rate for women in the world. And while the overall U.S. incarceration rate is falling, the women’s rate remains at a historic high. Only 4% of the world’s female population lives in the U.S., but the U.S. accounts for over 30% of the world’s incarcerated women. (

There are currently around 110,000 women in prison in the United States (The Sentencing Project). The number of women in prison has been increasing at a rate of 50% higher than men since 1980 and now stands nearly 8 times higher than 3 decades prior. Over the past quarter century, there has been a profound change in the involvement of women within the criminal justice system. This is the result of more expansive law enforcement efforts, stiffer drug sentencing laws, and post-conviction barriers to reentry that uniquely affect women. More than 60% of women in state prisons have a child under the age of 18. (The Sentencing Project).

Women are typically committing crimes which are part of their survival. The majority of criminal offenses are often drug related and mental illness and poverty are high risk factors for women who commit crimes. 70% of incarcerated women have a mental illness and 90% have experienced trauma, most live in poverty, are often unemployed, and many have children but no support or other means to take care of their families.

Race and ethnicity also play a role when looking at statistics around incarcerated women. In 2017, the imprisonment rate for African American women (92 per 100,000) was twice the rate of imprisonment for white women (49 per 100,000). Hispanic women were imprisoned at 1.3 times the rate of white women (67 vs. 49 per 100,000). The rate of imprisonment for African American women, however, has been declining since 2000, while the rate of imprisonment for white and Hispanic women has increased. (The Sentencing Project).

All U.S. prisons and jails are required to provide prenatal care under the Eighth Amendment to the Constitution, but no detailed federal standards have been set to ensure that women are actually receiving the care they need. According to recent data from the Johns Hopkins School of Medicine, in some states, over 20% of prison pregnancies resulted in miscarriages; in others, preterm birth rates exceeded the national average (about 10%). 

The National Commission on Correctional Health Care (NCCHC) has published a set of standards for the treatment of pregnant women in prison, such as appropriate medical examinations as a component of prenatal care, specialized treatment for pregnant women with substance use disorders, and limited use of restraints throughout the course of the pregnancy. Often states fail to make their Department of Corrections policies publicly available, or even write guidelines on the care of incarcerated pregnant women in the first place. 

Incarcerated pregnant women are particularly vulnerable to pregnancy complications related to substance use disorders, poor nutrition, and sexually-transmitted infections because they often come from precarious social and economic environments that exacerbate these risk factors. Yet data shows that the lack of codified protocols for the care of pregnant women in state prisons is a widespread issue, and even policies that do exist frequently do not include adequate provisions for basic medical needs.

Initiatives like the Alabama Prison Birth Project are by no means standard at all female prisons in the US. “Most prison doula projects have been initiated outside of the corrections departments. In Alabama, the program was court ordered and luckily the prison really sees the benefits and wants it to continue as well,” Ashley explains. “Some other prison birth programs have come and gone in other states, but the projects in Minnesota and now Alabama are the longest standing. We are seeing new programs pop up, for example, in Michigan, Arkansas, and Virginia, but funding is always an ongoing issue.”

The Alabama Prison Birth Project's mission is to improve the health of newborns birthed by women in custody while strengthening maternal bonds and maternal self-efficacy. “When babies are born to incarcerated women they are generally born into poverty, often with parents who have experienced trauma and abuse and may self-medicate with substances.” Ashley explains. “We are working to break the cycle of ‘womb-prison’. When a woman has a baby, they see the opportunity to have a new start, wipe the slate clean – create a brighter future for their children,” she continues.

“Our vision is that all mothers giving birth in custody in Alabama will have healthy births and will not be separated from their newborns, ensuring normal child development and promoting positive maternal change from within,” she states.

The Alabama Prison Birth Project provides one-on-one, peer support to expectant mothers imprisoned in Alabama. Weekly prenatal and postpartum support and parenting education groups are offered at the facility. These 120-minute classes teach incarcerated pregnant mothers about bonding with their infant before and immediately after birth, breastfeeding, early infant development, and parenting. The classes, in addition to increasing the participants' maternal knowledge and skills, also provide an essential forum for community-building and social support.

“Simple, yet important items, like pregnancy and parenting books aren’t always available to these women. The Alabama Prison Birth Project stocks the prison library with these resources and also advocates for higher quality nutrition in meals for expecting and new mothers while incarcerated. We work together with food partners and Tutwiler to bring in a nutrient dense spread containing fruits, vegetables, proteins, calcium, Omega-3's, folate, and iron—an important intervention in improving the health of the developing fetus and the mother, both prenatally and during lactation.”

Giving birth while incarcerated is not a fairytale experience. “These women go into the hospital knowing they will come out empty handed,” Ashley says. She explains that the doula is notified when the inmate is in labor and they join them at the hospital. “We take pictures, bring a blanket and a hat for the baby. We try to capture whatever bonding can happen during the short period of time they have with their newborn,” Ashley explains. The doula leaves the mother 3 hours following the birth and comes back less than 24 hours later to support the mother before they have to leave their baby and return to the prison.

Prison social workers work with the pregnant inmate to complete the required paperwork for temporary re-assignment of custody prior to the birth. The person designated to be granted temporary custody is notified when the baby is born and can pick up the baby once the mother has been transferred out of the hospital and sent back to the prison. Visitors are not allowed during inmate births. In some unfortunate cases, the babies end up in foster care and are sometimes never reunited with the mother.

Ashley shares, “By building a strong support system amongst the incarcerated women in our group, we try to give them a feeling of returning to their ‘family’ even though they have to leave their baby with strangers in a nursery. Knowing they aren’t alone in this difficult process can be very comforting.” Ashley noted that prior to their project, inmates who gave birth were sent to another area of the prison post-birth and often felt isolated and depressed. (That policy has now been changed and they return to their former dorm that houses pregnant and post-partum women.) The doula visits the postpartum Mom again 2 days postpartum with photos of the birth to talk about how they feel. Meetings are arranged as often as necessary to check in, including having the women fill out questionnaires about their experience and make sure to discuss symptoms of postpartum depression.

Ashley continued, “We are not mental health care providers, but we do feel that it’s our job to limit traumatization as much as possible. We focus on creating community and support amongst the incarcerated women by offering consistency and a space to help them support each other.” “It’s difficult to fully treat trauma when the individual is living in a traumatic situation daily, but we try to mitigate the amount of trauma if possible, by showing compassion, providing proper treatment, and ensuring safety.”

New mothers inside Tutwiler, if they wish and are healthy, are able to express milk for their infants once they return to prison after giving birth, something which was not possible until the start of the Alabama Prison Birth Project. Ashley says, “Around 70% of our incarcerated clients choose to express some milk and are supported by the doulas through lactation consultations.” They can make use of the pumping room complete with rocking chairs, nursery decorations, hospital grade pumps and a freezer to store milk, which is then shipped on dry ice to the infant’s caregiver. “Only a mother can give her baby breast milk designed for that baby, and with this option, she can provide a form of everyday care, even as someone else cares for her baby,” Ashley reports.

Data has shown lower cesarean rates, lower risk of infants going to special care nurseries, lower preterm birth rates, and higher breastfeeding rates when mothers are accompanied by a companion during pregnancy and in the birth room.  

“By continuously nurturing them through their pregnancy and birthing time, modeling healthy relationships for them, validating their experience by reflecting back their feelings, and holding space around them as they welcome and separate from their newborns, they hope to encourage a continued connection between them and their babies. This connection is key to healthy infant outcomes, healthy infant development, and increased mental well-being and connection for the mother,” Ashley explains.

“Honestly, I have learned more from our clients than I have taught them,” Ashley says as she reflects. “When they get in touch and send photos and updates – that’s the biggest reward. Seeing them start their life again, get a job, keep custody of their kids… Knowing that we are able to help them carry the burden of the experience and look back on it with some good memories - we are privileged to do that work.”

All photos courtesy of: Elaine McMillion Sheldon

Learn more about the Alabama Prison Birth Project on their website

Or watch, Tutwiler, a documentary short from FRONTLINE and The Marshall Project, to get a firsthand glimpse into the lives of incarcerated pregnant women — and what happens to their newborns.

All profits related to this article go directly to the Alabama Prison Birth Project. You can make an additional donation on their website.

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