Mothers Behind Bars, National Womens Law Center, 2010

Mothers Behind Bars, National Womens Law Center, 2010

• Aug. 9, 2016 • Locations: United States of America • Topics: Discrimination, Gender Discrimination -- Women, OB/GYN, Mothers in Prison, Parental rights, Children of Prisoners

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Photo: © Rebecca Epstein

The Rebecca Project for Human Rights
2029 P Street, NW, Suite 301
Washington, DC 20036
202.265.3906
202.265.3909 (fax)
www.rebeccaproject.org
National Women’s Law Center
11 Dupont Circle, NW, Suite 800
Washington, DC 20036
202.588.5180
202.588.5185 (fax)
www.nwlc.org

Mothers
Behind
Bars:
A state-by-state report
card and analysis of
federal policies on
conditions of
confinement for
pregnant and parenting
women and the effect
on their children

ABOUT THE AUTHORS
The Rebecca Project for Human Rights is a Washington, DC-based nonprofit
organization advocating for justice, dignity and policy reform for vulnerable women
and girls in the United States and in Africa. We believe that women and girls possess
the right to live free of gendered inequity and violence, and that investment in their
leadership creates healthy, safe, and strong communities.
The National Women’s Law Center is a Washington, DC-based nonprofit organization working to expand opportunities and eliminate barriers for women and their
families, with a major emphasis on women’s health, education and employment
opportunities, and family economic security.
©2010 National Women’s Law Center

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ACKNOWLEDGEMENTS
Mothers Behind Bars: A state-by-state report card and analysis of federal policies on conditions of confinement for pregnant
and parenting women and the effect on their children is a collaborative endeavor that relies upon the work of many
individuals. At The Rebecca Project, the primary author of the Report Card, Malika Saada Saar, was greatly
assisted by Brittany Bisnott and Faiza Mathon-Mathieu. The Rebecca Project would like to recognize Angela
Day. The Rebecca Project would also like to acknowledge Gwen, Michelle, Arnita, Tessa, and Stephanie,
mothers who have been shackled during labor and delivery. At the National Women’s Law Center, the primary
author of the Report Card, Jill C. Morrison, was greatly assisted by Micole Allekotte, Lisa M. LeMair and
Grace Lesser. The authors would also like to thank members of the Mothering Behind Bars Coalition for
their guidance, with a special thanks to Diana Kasdan of the ACLU for allowing us to use their report, State
Standards for Pregnancy-Related Health Care in Prison (2008). We are also grateful for the assistance of Meghan
Rhoad at Human Rights Watch. Professor Brenda V. Smith of the Washington College of Law at American
University graciously lent her expertise to this effort.
Support for the Report Card was provided by the Ford Foundation, the Turner Foundation and the Moriah
Fund. The statements and views expressed herein are solely the responsibility of the Report Card authors, and
do not necessarily represent the views or positions of the funders.
DISCLAIMER
While text, citations, and data for the indicators are, to the best of the authors’ knowledge, current as the
Report Card was prepared, there may well be subsequent developments, including recent legislative actions,
that could alter the information provided herein. This report does not constitute legal advice; individuals and
organizations considering legal action should consult with their own counsel before deciding on a course of
action. In addition, this report does not constitute medical advice. Individuals with health problems should
consult an appropriate health care provider.

Table of Contents
EXECUTIVE SUMMARY.................................................................................................................................. 5
INTRODUCTION............................................................................................................................................. 9
Why a Report Card on Mothers Behind Bars?...................................................................................... 9
Goals and Limitations of this Report Card.........................................................................................10
Indicator Descriptions............................................................................................................................11
Conclusion...............................................................................................................................................13
State-by-State Report Cards............................................................................................................15
Prenatal Care............................................................................................................................................16
Shackling Policies...................................................................................................................................17
Family-Based Treatment as an Alternative to Incarceration...........................................................19
Prison Nurseries......................................................................................................................................20
GRADing THE STATE LAWS AND DEPARTMENTS OF CORRECTION POLICIES ............................23
Prenatal Care...........................................................................................................................................23
Shackling During Labor and Delivery.................................................................................................25
Family-Based Treatment as an Alternative to Incarceration...........................................................29
Prison Nursery Programs......................................................................................................................30
FEDERAL POLICIES AND RECOMMENDATIONS FOR IMPROVEMENT................................................33
Prenatal Care............................................................................................................................................34
Shackling..................................................................................................................................................35
Alternatives to Incarceration.................................................................................................................36
Prison Nurseries......................................................................................................................................37
Methodology..........................................................................................................................................39
Endnotes...................................................................................................................................................42

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Photo: ©Mark Allen Johnson

EXECUTIVE SUMMARY
There are now more women behind bars than at any other point in U.S. history. Women have borne a
disproportionate burden of the war on drugs, resulting in a monumental increase of women who are facing
incarceration for the first time, overwhelmingly for non-violent offenses. This rampant incarceration has a
devastating impact on families. Most of these women, unseen and largely forgotten, are mothers. Unfortunately,
pregnant women, incarcerated women and their children are subject to federal and state correctional policies1
that fail to recognize their distinct needs or honor their families.
The Rebecca Project and the National Women’s Law Center collaborated on this Report Card, which
analyzes federal and state policies on prenatal care, shackling, and alternative sentencing programs and grades
states on whether their policies help or harm incarcerated women in these key areas.2 This effort is intended to
help advocates assess their own state’s policies affecting these significant phases of pregnancy, labor and delivery,
and parenting.3
The Report Card also provides an analysis of related federal laws and policies regarding conditions of
confinement for women in federal prisons and immigration detention facilities. Additionally, it assesses how
the federal government funds state programs that serve incarcerated pregnant or parenting women. For reasons
discussed below in the federal findings section, the federal government does not receive a grade. Rather, the
Report Card identifies areas where the federal government is making commendable gains in the humane
treatment of incarcerated women who are pregnant or parenting and provides specific recommendations for
areas that need improvement.
Ultimately, our goal is to encourage federal and state governments to reevaluate policies that fail to protect the
interests of this growing at-risk population and adopt policies that recognize the needs of incarcerated pregnant
women and mothers, as well as their children. But we also know that good laws and policies are not enough.
Just as critical is whether state and federal institutions actually comply with what is required and whether they
punish and correct violations. Just because a state has a high grade in any particular area does not mean that the
pregnant and parenting women in that state are benefiting from the good policy. To the contrary, we know that
this is often not the case. In addition to encouraging policy makers to improve upon policies that affect the

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lives of pregnant and parenting women in prison and their children, we also hope that this Report Card will
help advocates identify institutions that are violating Department of Corrections’ policies or state law. It is only
when we call attention to violations and demand remediation and enforcement that laws and policies actually
accomplish their goals: improving the lives, health and future prospects of these vulnerable women and their
children.
States that demonstrate a formal commitment to a woman’s civil and human rights by having policies that
require pregnant women to have access to prenatal care, restrict the use of restraints on pregnant women, and
maintain and strengthen the mother-child bond through the use of alternative sentencing receive the highest
marks. Grades are provided to allow comparisons between states regarding their formal laws and policies. An
“A” grade does not mean that a state’s policy could not be improved to better meet the needs of pregnant and
parenting women who are incarcerated.
While the Report Card also examines states’ prison nursery programs, it is important to note that such
programs are far less desirable than sentencing these mothers to a community-based non-institutional setting.
The same characteristics that render women eligible for participation in a prison nursery program, including
being convicted of a non-violent offense, are very similar to those that would render them eligible for
alternative sentencing, if states chose to make such an option available. Therefore the Report Card does not
factor prison nurseries into the states’ overall composite grade, although it acknowledges the states which have
these programs.

State Findings
Overall grades: Averaging the grades for prenatal care, shackling, and family-based treatment as an
alternative to incarceration, twenty-one states received either a D or F, both of which are considered failing
grades. Twenty-two states received a grade of C, and seven received a B. The highest overall grade of A- was
earned by one state—Pennsylvania.
Prenatal care: Thirty-eight states received failing grades (D/F) for their failure to institute adequate policies,
or any policies at all, requiring that incarcerated pregnant women receive adequate prenatal care, despite the
fact that many women in prison have higher-risk pregnancies.
Forty-three states do not require medical examinations as a component of prenatal care.
Forty-one states do not require prenatal nutrition counseling or the provision of appropriate nutrition to
incarcerated pregnant women.
Thirty-four states do not require screening and treatment for women with high risk pregnancies.
Forty-eight states do not offer pregnant women screening for HIV.
Forty-five states do not offer pregnant women advice on activity levels and safety during their pregnancies.
Forty-four states do not make advance arrangements for deliveries with particular hospitals.
Forty-nine states fail to report all incarcerated women’s pregnancies and their outcomes.
Shackling: Thirty-six states received failing grades (D/F) for their failure to comprehensively limit, or limit
at all, the use of restraints on pregnant women during transportation, labor and delivery and postpartum
recuperation.
There has been a recent increase in states adopting laws that address shackling, now totaling ten. Of the states
without laws to address shackling:
Twenty-two states either have no policy at all addressing when restraints can be used on pregnant women
or have a policy which allows for the use of dangerous leg irons or waist chains.

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When a pregnant woman is placed in restraints for security reasons, eleven states either allow any officer to
make the determination or do not have a policy on who determines whether the woman is a security risk.
Thirty-one states do not require input from medical staff when determining whether restraints will be
used.
Twenty-four states do not require training for individuals handling and transporting incarcerated persons
needing medical care or those dealing with pregnant women specifically, or have no policy on training.
Thirty-one states do not have a policy that holds institutions accountable for shackling pregnant women
without adequate justification.
Thirty-four states do not require each incident of the use of restraints to be reported or reviewed by an
independent body.
Family-Based Treatment as an Alternative to Incarceration: Seventeen states received a failing grade (F) for
their lack of adequate access to family-based treatment programs for non-violent women who are parenting.
Seventeen states have no family-based treatment programs, while thirty-four states make such programs
available.
Of the thirty-four states with family-based treatment programs, thirty-two offered women the option to
be sentenced to these programs in lieu of prison, while two did not.
Prison Nurseries: Thirty-eight states received failing grades (D/F) for failing to offer prison nurseries to new
mothers who are incarcerated. While a far less preferred option than alternative sentencing, prison nursery
programs still provide some opportunity for mother-child bonding and attachment.
Thirty-eight states do not offer any prison nursery programs.
Of the thirteen states that do offer such programs, only two allow children to stay past the age of two.
Three of the thirteen programs offer therapeutic services for both mother and child.

Federal Findings
The vast majority of pregnant and parenting women are confined in state prisons, but the federal government
also plays an important role in providing humane treatment to this vulnerable population. In addition to
operating facilities for women who are convicted of federal crimes, the federal government also oversees the
Immigration and Customs Enforcement agency of the Department of Homeland Security (ICE). ICE detains
individuals who are in violation of civil immigration laws pending deportation. While this detention is not
incarceration, per se, pregnant and parenting women who are held in ICE custody are totally under the control
of the agency. And finally, Congress has the ability to appropriate federal funds to the states, including funds
that must be used for programs that serve pregnant and parenting women who are incarcerated. Thus, the
federal government can play a crucial, if indirect, role in affecting conditions of confinement for pregnant and
parenting women in state custody.
We provide a summary of the findings below and discuss recommendations for improvement in the federal
section, but there are several reasons no grade was assigned to the federal policies. First, the federal government
stands alone, in contrast to the states, for the purposes of comparison. Second, the data is not currently available
to accurately assess how many more programs the federal Bureau of Prisons (BOP) should have to adequately
serve the population of pregnant and parenting women in its twenty-eight facilities across the nation.
Furthermore, there are valid reasons for the BOP’s decision to operate certain programs only within a limited
number of facilities. And third, some of the areas examined in the federal section, including funding of state
programs and ICE detention policies, have no equivalent on the state side.
Moreover, each of the federal areas we examine is controlled by a different government entity, so having one
grade in each of the four areas would not fairly reflect each entity’s respective investment in the pregnant

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and parenting women under its jurisdiction. ICE detention facilities are overseen by the Department of
Homeland Security, federal funding to the states is controlled by Congress, and the BOP has oversight of
federal prisons. These factors make it difficult to fairly assign a grade to the federal government’s range of
efforts regarding pregnant and parenting women. Instead, the Report Card provides specific recommendations
that would improve the health and well-being of pregnant and parenting women under federal jurisdiction and
suggestions for funding to the states to do the same.
Federal Bureau of Prisons (BOP)
While the BOP’s prenatal care policy is comprehensive in addressing the unique needs of incarcerated
pregnant women, information on the actual care provided is sparse and reports indicate that access to
prenatal care is inconsistent.
The BOP is to be commended for showing leadership in developing a policy to prohibit the shackling of
pregnant women during labor and delivery. There is not yet information regarding the implementation of
this policy.
The BOP has a program called Mothers and Infants Nurturing Together (MINT), which provides
alternative community-based sentencing for women who have recently given birth and have less than five
years left on their prison terms. Currently MINT serves only a small portion of mothers in federal prison.
Access is restricted to newborns, but older children would also benefit from the program.
The federal BOP does not operate any prison nurseries. Rather than initiate prison nurseries, we
recommend the expanded use of alternative sentencing within the MINT program, described above.
Immigration and Customs Enforcement (ICE) Detention
ICE is in the process of revising its policies regarding the confinement of individuals detained for
immigration violations, including the health care to be provided to certain detainees.
There is currently no prohibition on shackling pregnant detainees. ICE officials have been largely
unresponsive to advocates’ request to implement a policy restricting shackling that mirrors the federal BOP
policy.
Alternatives to ICE detention are available, yet immigration attorneys report inconsistent implementation
as well as government resistance to having detainees released into the community; there is little
information available regarding the use of community release for pregnant and parenting detainees.
Conditions for families with children in ICE detention are poor. Included in the above-mentioned
overhaul of ICE detention is a plan to better serve the needs of families with children. We look forward to
reviewing these changes.

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Why a Report Card on Mothers
Behind Bars?

Photo: ©Mark Allen Johnson

INTRODUCTION

Mothers behind bars are invisible to most of us.4 To the
extent they are thought of at all, they are caricatured
as the ultimate bad mother who has violated the basic
maternal commitment to care for her children by engaging
in wrongful criminal activities. But, in truth, mothers’
pathways to incarceration are complex, and often rooted in
issues of sexual and physical violence.
Most incarcerated women, including mothers behind
bars, were first victims of violence.5 The shared narrative
arc of incarcerated women and mothers behind bars is
that of repeated experiences of brutal sexual and physical
victimization, generally begun during girlhood. In the
absence of access to mental health services, many of
these vulnerable mothers turned to self-medicating with
illegal substances.6 Rather than being treated for trauma,
depression, addiction, and the other indelible injuries
of violence, these mothers have been displaced into the
criminal justice system.
Twenty-five years ago, the presence of women—especially
mothers—was an aberration in the criminal justice system.7
Following the introduction of mandatory sentencing to
the federal drug laws in the mid-1980s, the number of
women in prison has risen by 400%.8 The percentage of
females incarcerated for drug offenses now surpasses that
of males.9 Most of these women are non-violent, first-time
offenders.10
This relatively recent phenomenon of criminalizing
mothers for trauma and addiction, precipitated by the war
on drugs and mandatory minimums, as well as the dearth
of programs for pregnant and parenting mothers, have
wreaked havoc on family stability and children’s well-being.
Most incarcerated mothers have minor children and were,
before their incarceration, the primary caretakers of their
children.11 Maternal incarceration wrongly leaves the child
behind, without recognition of a child’s fundamental need
for his or her mother.12
Prison rules and regulations, harsh and dehumanizing
for all who are confined, were originally developed to
serve an overwhelmingly male population convicted of
violent crimes.13 The system has been largely unresponsive
to changes that would better meet the needs of and

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rehabilitate the overwhelmingly non-violent population of incarcerated women, including those who are
pregnant and parenting. Unsurprisingly, the system also generally fails to account for the needs of the children
left behind.
Unfortunately, discourse on criminal justice policy, review of conditions of confinement, alternative
sentencing, and reentry reform tend to either ignore or marginalize the significance of the growing number of
incarcerated women, especially those who are parenting.14 Similarly, the Federal Bureau of Prisons (BOP) and
state departments of corrections (DOC) have yet to fully recognize the distinct gender- and family-specific
considerations of incarcerating pregnant women and mothers with minor children. There are few prison-based
programs specifically designed for pregnant and parenting women. The inadequacy of services for these women
is not limited to incarceration settings, but affects women at every point in their involvement with the criminal
justice system. Pre-trial diversion and release services, court-sentenced alternatives and re-entry programs for
mothers are restricted in number, size, and effectiveness because the system was developed to serve men.

Goals and Limitations of this Report Card
The purpose of this Report Card is to expose the conditions of confinement for pregnant and parenting
women and to identify specific steps that can be taken by policy makers and advocates to improve conditions
for these women and their children. It is an effort to unearth how incarcerated women and mothers are treated
by federal and state correctional facilities during the significant phases of pregnancy, labor and delivery, and
parenting.
It is also critically important to recognize the overwhelming problem of rampant over-incarceration. The U.S.
has over one and a half million people incarcerated, a higher per capita incarceration rate than any other nation
in the world.15 Very little attention has been paid to the costs of confinement on the dignity and humanity of
the now more than two million people who are imprisoned in the United States. The Report Card focuses on
policies affecting the conditions of confinement for pregnant women and mothers, but we encourage states
and the federal government to take a serious look at the types of investments in social services, education,
mental health care and drug treatment and addiction prevention to stem the tide of over-incarceration. It
is clear that incarceration has both financial and human costs. Redirecting the massive resources currently
devoted to imprisonment will save far more than money; it will strengthen families, improve the quality of
lives, and help millions escape the indignities that are inherent in imprisonment.
At the outset, it is important to note that the mere existence of a good policy, and correspondingly good grade,
says nothing about the actual implementation of the policies.16 Laws and policies that are intended to meet the
needs of incarcerated women and mothers are only meaningful if those who are responsible for effectuating
them are properly educated and trained, and if serious repercussions are in place if they fail to follow the laws
and policies. We know that simply because it is written somewhere that an incarcerated woman is entitled to
receive prenatal care does not mean that every pregnant woman actually receives it. We know that despite laws
and policies to the contrary, mothers are shackled without corrections officers following the legally mandated
procedures.
Indeed, the goal of this Report Card is two-fold: first, to identify how states and the federal government
can adopt improved policies of confinement for incarcerated women and mothers and second, to assist
advocates for incarcerated women and mothers in identifying what policies are currently in place to meet
the unique needs of pregnant and parenting women. It is our hope that advocates around the nation will use
this information to identify institutions that are violating state law or their own DOC policies and demand
better implementation of policies intended to protect pregnant women and preserve the sacred bond between
mothers and their children. For more information on what you can do to improve conditions for pregnant and
parenting women behind bars, please contact us at info@rebeccaproject.org.

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Indicator Descriptions
Prenatal Care
The inadequacy of health care for all people in U.S. prisons has been well documented, despite the Supreme
Court’s ruling that people who are incarcerated are entitled to health care under the Eighth Amendment
of the U.S. Constitution.17 As with other facets of prison life, the prison health care system was originally
established to serve a predominately male prison population.18 For this reason, while most health care in a
prison setting could be described as barely adequate at best for men falls even shorter from meeting the basic
needs of women. Care for pregnant women is even more dismal, considering their additional health needs.19
Moreover, women in prison are less likely than women who have not been incarcerated to have had access
to regular health care before entering prison.20 They often have undiagnosed or untreated chronic conditions
such as depression, diabetes, hypertension and asthma that can increase pregnancy risks and contribute to poor
birth outcomes. Certain conditions that increase pregnancy risks, including drug addiction, hepatitis, and STDs,
are also more prevalent in women who are imprisoned.21
Pregnant women who are imprisoned, like other women, need high quality health care.22 Failure to comport
with nationally recognized standards for prenatal care results in poor health outcomes for children born
to women who are imprisoned.23 In addition to the immediate and long term harms to women provided
inadequate care during their pregnancies, there is also harm to their children. The children may live with lifelong health problems that result from their mothers’ failure to receive proper nutrition during pregnancy, or to
receive treatment for health conditions that contribute to poor pregnancy outcomes.

Shackling Mothers During Labor and Delivery
The dangerous practice of shackling pregnant women is being reconsidered and in many cases prohibited
due to both proven and potential harm to the mother and child. Restraints make it difficult for doctors to
adequately assess the condition of the mother and the fetus, and to provide prompt medical intervention when
necessary. Restraints also make the process of labor and delivery more painful. 24 The Federal Bureau of Prisons
(BOP) in September 2008 ended shackling pregnant inmates as a matter of routine in all federal correctional
facilities.25 State legislatures and departments of corrections have begun to respond to the consensus against
shackling. Most recently, California, Colorado, Illinois, New Mexico, New York, Pennsylvania, Texas,Vermont,
Washington and West Virginia have enacted laws prohibiting the practice of shackling pregnant women.26
While there is no systematic documentation at the state or federal level of how many women give birth while
incarcerated, in 2007, the Bureau of Justice Statistics stated that, on average, five percent of women who enter
into state prisons are pregnant and six percent of women in jails are pregnant.27
Yet some prisons continue to use restraints on women in labor and delivery as a matter of course, regardless
of a woman’s history of violence, whether she has ever absconded or attempted to escape, or her state of
consciousness.28 As important as whether shackling is allowed is limitations on the type of restraints used on
pregnant women. In October 2007, both the BOP and U.S. Marshals agreed to the cessation of “belly shackles”
or shackles that constrict the stomach area of pregnant women, regardless of the trimester of pregnancy, unless
they can show a legitimate security justification.29

Family-Based Treatment as an Alternative to Incarceration
Against the backdrop of the crack epidemic in the 1980s, growing numbers of mothers were turned away from
treatment because traditional treatment programs did not allow children on the premises or include children
in the delivery of services. In 1992, Congress responded by providing funding to establish residential treatment
programs for pregnant and postpartum women and children. The Substance Abuse and Mental Health Services

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Administration (SAMHSA) Center for Substance Abuse Treatment (CSAT) awarded $241 million over a fiveyear period between FY 1993-1997 to create fifty family treatment programs. Unfortunately, Congress did not
provide funding to sustain these programs. Since FY 2004, funding has been provided to operate an average of
fourteen family treatment programs per year.
Data demonstrate that two-thirds of incarcerated women have at least one minor child.30 When a father is
incarcerated, ninety percent of the time his child will live with the mother. Comparatively, when a mother
is incarcerated, only twenty-five percent of the time will her child live with the father.31 Because maternal
incarceration is very destabilizing to a family’s health and stability, programs that allow mothers with minor
children to be sentenced to community-based facilities are far better suited for this population. Studies have
long established that women have a lower risk of violence and community harm, thus women are often the
ideal prison population for community-based alternative sentencing programs.
In order to maximize the success of women sentenced to community-based programs, it is critical for
the programs to include comprehensive services, including therapy, parenting classes, and substance-abuse
treatment. Family-based treatment programs as a sentencing alternative permit mothers and children to
heal together and demonstrate consistently successful outcomes for children’s health and stability, family
reunification, reduced rates of recidivism, and sustained parental sobriety.32 Moreover, it is less costly than
incarceration and achieves better outcomes than those achieved by maternal incarceration and a child’s
placement in foster care.
Unlike prison nursery programs, these programs allow mothers to be not only with newborns, but with their
other children as well. Some programs allow children to live with their mothers, while others give mothers
the opportunity to interact with their children within the context of the community rather than a lock-down
facility. Developing the mother-child relationship has shown considerable rehabilitative effects, including
improved outcomes for economic independence and lowered recidivism rates.33
In 2003, CSAT evaluated family residential treatment programs, and found that, at six months post-treatment:34

60% of the mothers remained completely clean and sober.
Criminal arrests declined by 43%.
44% of the children were returned from foster care.
88% of the children treated in the programs with their mothers remained stabilized, six months after
discharge.
Employment rose from 7% before treatment to 37% post-treatment.
Enrollment in educational and vocational training increased from 2% prior to treatment to 19% posttreatment.35
It is important to note that the Report Card focuses on alternative sentencing only for mothers who are nonviolent offenders suffering with an untreated addiction. The uptick in maternal incarceration is directly related
to the war on drugs and the criminalization of untreated addiction. Most mothers behind bars are there for
crimes related to their untreated addiction. They continue to struggle with addiction during and after their
incarceration, and recidivate because of their untreated addiction. These mothers constitute the majority of
women behind bars—and represent this new phenomenon of maternal incarceration—such that it only makes
sense to propose alternative sentencing to family treatment programs for this specific population.

Prison Nurseries
When mothers are incarcerated, their children are usually placed either in foster or kinship care.36 During
the period of incarceration, it is a struggle for incarcerated mothers to maintain an abiding connection to
their children.37 Women’s prisons are often located in rural areas far from the cities in which the majority
of incarcerated women live, making it difficult to maintain contact with their children and jeopardizing the
12

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prospects of successful reunification.38 More than half of mothers never receive visits from their children
during the time they are incarcerated.39 Incarcerated mothers with children in foster care are often unable to
meet court-mandated family reunification requirements for contact and visitation with their children, and
consequently lose their parental rights.40
Studies show that the children left behind as a result of maternal incarceration are vulnerable to suffering
significant attachment disorders.41 They are more likely to become addicted to drugs or alcohol, engage
in criminal activity, manifest sexually promiscuous behavior, and dangerously lag behind in educational
development and achievement.42 Children of incarcerated mothers labor under their own sentences, their own
punishment of having their mothers taken from them.
Prison nurseries are far from ideal. Considering that most women are convicted of non-violent crimes, we
urge federal and state policy makers to seriously reconsider whether a new mother needs to be imprisoned at
all. Reports from mothers with children in prison nurseries indicate that their babies’ close proximity allows
prison staff to coerce and manipulate a mother by threatening to deny her access to her baby. The far better
option is alternative sentencing, which, as described above, allows a woman to parent her children, receive
the services she needs to reduce her future chances of incarceration, and enter society as a productive, healthy,
whole individual.
Nonetheless, prison nursery programs, while far less desirable than alternative sentencing, provide a way to
keep mothers and children together during a crucial period of child development.43 Only mothers who
are convicted of non-violent crimes and do not have a history of child abuse or neglect are allowed to
participate.44 Research demonstrates that these programs can yield effective outcomes for mothers and their
children.45 Mothers who participate in prison nursery programs show lower rates of recidivism.46 Moreover,
the mother-child bond is preserved during a formative and critical time in an infant’s development, and the
emotional and financial costs of foster care involvement are avoided.47

Conclusion
It is the intent of this Report Card to encourage all concerned stakeholders—including federal and state
corrections officials, policy makers, and advocates—to take action on behalf of this often forgotten population.
Despite the invisibility of these women, it is in society’s interest to support policies that advance the health
and well-being of pregnant and parenting women who are incarcerated and their children. Compelling
evidence shows that programs specifically tailored to address the needs of these vulnerable families can have
a tremendous impact on their lives and health. Programs and policies that recognize the unique needs of
pregnant and parenting incarcerated women enable them and their families to break the continued cycle of
abuse, addiction and incarceration, and instead become valued contributors to their communities.

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Illinois Department of Corrections: Focusing on the Needs of Pregnant and
Parenting Inmates
The Illinois Department of Corrections (DOC) has implemented many reforms focusing on the needs of
pregnant and parenting inmates. Recognizing that there are distinct differences in dealing with women,
in 1999 Illinois centralized all decision regarding their care within the office of Women and Family
Services, headed by Deputy Director Debbie Denning.48 Both the National Institute of Corrections and
the American Correctional Association have acknowledged Illinois’ leadership in establishing a separate
division within its Department of Corrections.49 This Division addresses the care of female inmates “in the
areas of trauma, abuse, assertiveness, medical and mental health care, substance abuse, parenting and child
reunification.”50
Unfortunately, in 2009 a new corrections director reorganized the Department, giving less authority to
the Division and merging it under the function of the Chief of Programs and Support Services. There has
been some progress toward restoring attention to women’s services in 2010.
The Illinois DOC runs several programs for female inmates and their children, in recognition of the
numerous studies showing that healthy family relationships are an integral part of women’s rehabilitation
and successful reentry into their communities.51 Children also benefit from developing nurturing
attachments to their mothers, so these programs also reduce the chances of these children one day
entering the criminal justice system.52
A prison nursery program initiated in 2007 at the Decatur Correctional Center called “Moms and Babies”
provides mothers the opportunity to bond with their newborns.53 The Moms and Babies Program can
accommodate five mothers and their babies, but has the long-term goal of being able to accommodate
up to twenty pairs.54 The program includes an Infant Development Center, which provides daycare while
participating mothers attend their prison jobs or classes.55 Additionally, each of the five prisons for women
in Illinois includes a child-friendly visitation area where mothers can read with their children, watch
videos or play on the floor.56 Family activities range from day camps, video visiting, and holiday activities
for mothers and children.57 Parenting programs are offered to all inmates, no matter their security level.58

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Photo: ©Rebecca Epstein

State-by-State
Report Cards
Overall Composite Grades
State

Prenatal Care

Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming

F
D
F
F
C
D
D
C
D
C
F
F
D
D
D
F
D
F
F
F
F
C
F
F
F
F
F
D
F
C
D
C
C
B
F
D
B
C
B
F
F
F
F
C
F
F
F
C
F
F
F

Shackling Policies

D
D
D
D
B
AD
F
C
F
F
D
D
B
D
D
D
D
F
D
D
F
D
C
D
D
F
D
D
D
D
AAF
D
D
C
D
AD
D
C
D
AD
AD
AB
C
D

Family-Based
Treatment as an
Alternative to
Incarceration

A
C
A
A
A
A
C
F
F
A
A
A
F
A
F
A
F
A
A
F
A
A
A
A
F
A
A
A
F
F
F
A
A
F
A
A
A
A
A
A
F
F
A
A
A
F
F
F
A
A
F

Composite Grade
CD+
CCB
BD+
DD
C
D+
CDBDCDCD+
F+
CC
CC
F+
CD+
C
F+
D
DB+
B+
D
CC
B
C+
ACF+
DCB+
CD+
F+
CC+
C
F+

Note:The prison nursery score is not included in the composite grade, as it is a far less
desirable policy than alternative sentencing, and serves the same population of non-violent
women who are being convicted of their first offense

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Prenatal Care
State

Prenatal nutrition
counseling or
Preexisting
Report of all
Advice on activity
the provision Offers HIV testing arrangement for
pregnancies and
levels and safety
of appropriate
deliveries
their outcomes
nutrition

Medical
examinations as
a component of
prenatal care

Screening of
and treatment
for high risk
pregnancies

Yes=5; No =0

Yes=3; No=0

Required=3;
Mentioned=1; No=0

Yes=3; No=0

Yes=1; No=0

0
5
0
0
0
0
0
0
0
0
5
0
5
0
0
5
5
0
5
0
5
5
0
-

3
0
3
0
3
3
3
3
0
3
3
3
3
0
3
0
3
3
3
3
3
0
3
-

0
3
0
3
1
0
3
1
0
1
1
1
3
3
3
1
3
1
3
1
3
1
3
-

0
3
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
3
3
0
-

0
0
0
1
1
0
0
0
1
0
0
0
0
1
0
0
1
0
1
0
1
0
0
-

0
0
0
0
1
0
0
0
0
0
1
0
0
1
0
1
0
0
1
1
0
0
0
-

0
0
0
0
1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
1
0
0
0
-

Raw Score

3
11
3
4
7
3
6
4
1
4
10
4
11
5
6
7
12
4
13
6
15
9
6
-

Grade

F
D
F
F
C
D
D
C
D
C
F
F
D
D
D
F
D
F
F
F
F
C
F
F
F
F
F
D
F
C
D
C
C
B
F
D
B
C
B
F
F
F
F
C
F
F
F
C
F
F
F

Total possible points: 17

Grading Key for Prenatal Care
A=16-17
B=12-15
C=6-11
D=1-5
F=0 or – (could not find any information on policies)
For more information on how we evaluated these policies, please see pages 23 to 25.

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Shackling Policies

State

DOC requires
training for
DOC policy
DOC requires each
individuals handling/
Person who
includes
incident of use
Medical staff
State has a statute DOC has a policy
transporting
determines
consequences for
of restraints to
input considered
prohibiting the limiting the use of incarcerated persons
whether a woman
individuals and/or
be reported and
when applying
use of restraints
restraints
needing medical care
qualifies as a
institutions when
reviewed by an
restraints
or those dealing with
security risk
use of restraints
independent body
pregnant women
was unjustified
specifically
Transportation, labor,
delivery, recovery=25;
Transportation, labor,
delivery ONLY=20; No
statute=0

0
0
0
0
20
25
0
0
0
0
0
0
0
20
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
25
25
0
0
0
0
0
25
0
0
0
0
25
0
25
0
25
20
0
0

No restraints any time=10;
Handcuffs during
transportation OR after
delivery=6; Handcuffs
during transportation AND
after delivery=4; No limits
when restraints are used, or
leg irons and waist chains
are allowed, or no policy=0

0
4
0
0
*
*
4
10
0
0
0
*
0
0
0
6
0
0
0
10
0
4
0
0
0
0
*
*
0
4
6
0
*
6
0
6
0
*
4
*
0
*
*
10
6

Yes=1; No=0

0
0
0
0
*
*
1
1
0
1
1
*
0
1
0
1
0
1
0
1
0
1
0
1
*
*
0
1
0
*
1
1
1
1
*
1
*
0
*
*
1

Yes=1; No=0

Warden/Director=2;
Captain/Shift
Supervisor/Matrix=1;
Any Officer=0

Yes=2; No=0

Yes=1; No=0

0
0
0
0
*
*
1
0
0
0
0
*
0
1
1
1
0
0
0
0
0
0
0
0
1
0
0
*
*
0
0
0
0
*
0
0
0
1
*
0
*
1
*
*
0

1
1
2
1
*
*
1
1
0
0
1
*
0
2
1
1
1
1
0
1
1
1
1
1
2†
1
0
*
*
1
0
1
1
*
1
2
2
2
*
2
*
1
*
*
1
1

0
0
2
0
*
*
0
0
0
0
0
*
0
0
0
2
0
0
0
0
0
0
0
0
2†
0
2
*
*
0
2†
2
2
*
0
2
0
0
*
2
*
2
*
*
0
0

0
0
1
*
*
1
0
0
0
0
*
1
1
0
0
0
1
0
0
0
0
0
0
0
*
*
1
1
1
*
0
1
1
0
*
0
*
0
*
*
0

Raw Score

1
5
5
1
20
25
8
12
0
1
2
20
1
4
4
4
7
2
0
3
11
2
5
1
6
1
3
25
25
2
9
10
4
25
8
6
10
4
25
9
25
4
25
20
11
8

Grade

D
D
D
D
B
AD
F
C
F
F
D
D
B
D
D
D
D
F
D
D
F
D
C
D
D
F
D
D
D
D
AAF
D
D
C
D
AD
D
C
D
AD
AD
AB
C
D

†See over for grading key and explanatory notes
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Total possible points: 30

Grading Key for Shackling Policies
A=30
A-=25
B=20
C=10-17
D=1-9
F= 0 or – (could not find any information on policies)
For more information on how we evaluated these policies, please see pages 25 to 28.

Additional Notes on Grading
Nevada

Nevada does not have a written policy on the use of restraints on pregnant women and their grade is reflective of that.
However, it should be noted that reporting is done by the minute in Nevada prisons, there is gender-specific training
for transportation, and pregnant women are not housed in the general population. Once it is determined that a woman
is pregnant, she is then housed in the infirmary under the supervision of doctors and nurses. It is this aspect that should
be modeled in other states. Nonetheless, it is suggested that Nevada adopt an official policy.
Ohio

All women are placed in leg irons and waist chains during transport, however, within the facility handcuffs are usually
used. While physically immobilizing restraints are used in severe situations, pregnant women are never restrained to
beds by their arms, legs or chests. Pregnant women are restrained with handcuffs secured in front of their bodies. In
the hospital, leg irons are used. During delivery all restraints are removed. When delivery is complete, the restraints are
reapplied. Women are never restrained when carrying their infants. Physically immobilizing restraints are only used at
the request of the treating physician.
Utah

Whenever a woman is determined to be a security risk, the determination is always made by medical personnel and
not an officer.
Additional Details on States with Statutes Limiting the Use of Restraints

We use an asterisk to indicate when a policy falls outside of the range of possibilities presented by our question. This
may mean that either: (1) the policy does not explicitly meet our criteria and we are awarding it points because it
meets the needs of pregnant women, or (2) that it technically meets our stated criteria but something about the policy
makes it ineffective in meeting its purported goals.

State

DOC requires training for
individuals handling/
transporting incarcerated
persons needing medical
care or those dealing with
pregnant women specifically

DOC requires each incident
of use of restraints to be
reported and reviewed by an
independent body

Person who determines
whether a woman qualifies
as a security risk

Medical staff input
considered when applying
restraints

DOC policy includes
consequences for individuals
and/or institutions when use
of restraints was unjustified

Yes

No (absent an event)

Yes

California

Yes

Illinois

Colorado

Yes

New Mexico

Yes

Pennsylvania

Yes

Texas

Yes

Vermont

New York

Yes

Washington

West Virginia

Yes

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Family-Based Treatment as an Alternative to Incarceration
State

DOC sentences
mothers to familyState has a familybased treatment
based treatment
programs as an
center
alternative to
prison
Yes=5; No =0

Yes=5; No=0

5
5
5
5
5
5
5
0
0
5
5
5
0
5
0
5
0
5
5
0
5
5
5
5
0
5
5
5
0
0
0
5
5
0
5
5
5
5
5
5
0
0
5
5
5
0
0
0
5
5
0

5
5
5
5
5
0
0
0
5
5
5
0
5
0
5
0
5
5
0
5
5
5
5
0
5
5
5
0
0
0
5
5
0
5
5
5
5
5
5
0
0
5
5
5
0
0
0
5
5
0

Raw Score

10
5
10
10
10
10
5
0
0
10
10
10
0
10
0
10
0
10
10
0
10
10
10
10
0
10
10
10
0
0
0
10
10
0
10
10
10
10
10
10
0
0
10
10
10
0
0
0
10
10
0

Grade

A
C
A
A
A
A
C
F
F
A
A
A
F
A
F
A
F
A
A
F
A
A
A
A
F
A
A
A
F
F
F
A
A
F
A
A
A
A
A
A
F
F
A
A
A
F
F
F
A
A
F

Grading Key for Family-Based Treatment as an Alternative to Incarceration

Total possible points: 10

A= 10
C= 5
F= 0 or – (could not find any information on policies)
For more information on how we evaluated these policies, please see pages 28 to 29.

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Prison Nurseries
DOC offers
Age at which the
mothers access to
Program is
child must leave
a prison nursery community-based
the program
program

State

Yes=1; No =0

Yes=1; No=0

1
0
1
1
1
1
1
1
1
1
1
1
1
1
-

0
0
0
0
0
1
0
0
0
0
0
0
-

2+ years=3; 1-24
months=2; 0-30
days=1

2
0
1
2
2
2
2
2
2
1
3
1
3
2
-

Program provides
Program
therapeutic
places focus on
services for
improving the
mother and/or
mother-child
child
relationship
Both=2; Mother or
Child=1; Neither=0

Yes=1; No=0

0
0
0
2
1
2
1
1
2
1
1
0
-

1
0
1
1
1
1
1
1
1
1
1
0
-

Raw Score

Grade

4
0
3
6
5
7
5
5
6
4
6
2
4
3
-

F
F
F
F
C
F
F
F
F
F
F
F
C
B
B
F
F
F
F
F
F
A
F
F
F
F
F
B
F
F
F
F
B
F
F
B
F
F
F
F
F
C
B
D
F
F
F
C
C
F
F

Total possible points: 8

Grading Key for Prison Nurseries
A=7-8
B=5-6
C=3-4
D=1-2
F=0 or – (could not find any information on policies)
For more information on how we evaluated these policies, please see pages 29 to 30.

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Oregon’s Children of Incarcerated Prisoner’s Project: Parenting Inside Out
The Coffee Creek Correctional Facility Parenting Inside Out (PIO) program is a parenting skills
curriculum designed to address the challenges that inmates experience while parenting in prison and
in planning to transition back into the family upon release.59 The curriculum, designed by a team
from the Oregon Department of Corrections and the Oregon Social Learning Center (OSLC), is an
evidence-based, cognitive-behavioral training program designed to help parents promote healthy child
adjustment, prevent problem behavior, and interrupt the cycle of inter-generational incarceration.60 The
curriculum offers interactive skill-building on child and adult development, parenting skills, and effective
communication through letters, calls, and visits.61
Parents accepted into the twelve week course receive regular instruction and attend several visits with
their children under the supervision of a family therapist, during which they cultivate specific skills such
as positive reinforcement and non-violent discipline. Preliminary outcomes from a five-year longitudinal
study of PIO found that the program had a significant positive impact on factors related to parental
stress and depression, level of interaction with children, ease of inmate-caregiver relationship and use of
non-violent discipline, along with a positive impact on re-arrest and employment rates for parents at six
months post-release.62

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Photo: ©Mark Allen Johnson

GRADing THE STATE LAWS AND DEPARTMENTS
OF CORRECTION POLICIES
This section provides detailed descriptions of the specific laws and policies on which we evaluated the
states. Each of the four areas, prenatal care, shackling, family-based treatment as an alternative to
incarceration and prison nurseries, has multiple specific policy components, which are discussed below.
The state is awarded varying points based on how close it comes to having a policy which meets the needs of
pregnant or parenting women who are incarcerated. These points are totaled for a raw score in each of the four
areas. The state’s grade in each of the four areas is based on the state’s total raw score compared to both the
total number of possible points and the raw scores of the other states.
The state’s total score for each indicator and its composite grade, the average of its scores in prenatal care,
shackling and alternative sentencing, are provided in the previous section, beginning on page 15. The prison
nursery score is not included, as it is a far less desirable policy than alternative sentencing, and serves the same
population of non-violent women who are being convicted of their first offense.

Prenatal Care63
Question 1—Does the state provide medical examinations as a component of
prenatal care?
It is important for pregnant women to receive medical examinations from a health care provider in order to
identify and presumably treat any problems with the pregnancy as soon as possible, and therefore improve
maternal and child health outcomes.64 States are awarded five points for specifying that pregnant women

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receive medical examinations,
meaning examinations conducted
by a professional with some
expertise in the treatment of
pregnancy conditions.

Question 2—Does the
state screen and provide
treatment for high-risk
pregnancies?
An essential factor in improving
birth outcomes is identifying highrisk pregnancies and providing
appropriate treatment to mitigate
the risks.65 Because women who
are imprisoned are more likely
to have conditions that render
their pregnancies high-risk, this is
an especially critical component
of their care. States that provide
screening and treatment receive
three points.

Question 3—Does
the state address the
nutritional needs of
pregnant women?
Proper nutrition is known to reduce
the incidence of certain birth
defects, premature birth and low
birth-weight.66 States are awarded
three points for requiring that
appropriate nutrition be provided.
Some states provide information
about nutrition, but do not ensure
a means of access to appropriate
nutrition. These states do not get
full credit, because a woman’s food
selection may be entirely limited
by what the facility makes available
in some cases. These states get
one point, however, since they at
least recognize the importance of
nutrition to pregnancy outcomes.

m ot h e r s b e h i n d b a r s

Pennsylvania Maternity Care Coalition’s MOMobile
Since 2006, the Maternity Care Coalition’s MOMobile program
has been demonstrating what services for incarcerated mothers
within the prison walls coupled with case management during
transition to community life can achieve. MOMobile works within
Philadelphia’s Riverside Correctional Facility, where it delivers the
education and support women need to prepare for reintegration
with their families and communities. The in-prison component is
coupled with individual case management for up to one year after
release, helping newly-released parents form strong ties to their
communities and positive relationships with their children.73
In only three years of operation, the MOMobile program has
shown results: stronger relationships and increased parenting and
community skills have resulted in a recidivism rate of just twentythree percent;74 in the program’s first two years of operation, only
34 participants returned to Riverside Correctional Facility.75 Not
only does MOMobile reduce recidivism among the mothers it
serves, it also educates mothers to improve the health and welfare
of their children. More than two-thirds of MOMobile participants
improved their knowledge of prenatal, postpartum, and childrelated issues as a result of the program.76
MOMobile works to improve maternal and prenatal health, as
well as the birthing experience. MOMobile staff has attended 34
births since the start of a doula program in May 2008.77 Doulas are
trained labor attendants who provide support to pregnant women
throughout their pregnancy, during birth and postpartum.78 The
program teaches parenting skills, mother child bonding, and positive
discipline skills, which has the potential to result in substantial
community-wide benefits if expanded to serve a greater percentage
of incarcerated mothers. MOMobile also provides support for the
caregivers of children born to incarcerated mothers, including
assisting with placement when family members are not available.
MOMobile has achieved great success, having served more than
300 women.79 The program was started with the support of a
four year, $113,000 matching grant from Robert Wood Johnson
Foundation Local Funding Partnerships, but this grant ended
in June 2010.80 MOMobile was turned down for funding from
the Department of Justice under the Second Chance Act.81
Unfortunately, with its limited funding, the program has been able
to serve only a fraction of the mothers in Riverside, and similar
programs do not exist for most incarcerated mothers and pregnant
women across the country. By stabilizing the lives of incarcerated
mothers before and after release, this program has shown early
successes in reducing recidivism and has the potential to have
far reaching impact on not only incarcerated women, but their
children and communities as well.

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Question 4—Does the state offer HIV Testing to pregnant women?
Women entering prison have a higher likelihood of being drug users than the general population.67 Some
women have been sex-workers in order to support their addictions.68 Studies also show that many, if not most,
women in prison have a history of sexual abuse.69 All of these factors place women in prison at heightened
risk of having been exposed to HIV. A pregnant woman who chooses to be tested and tests positive can begin
treatment to allow her a longer and healthier life.70 Testing also allows the facility to begin HIV prophylaxis
to reduce the odds of the baby being born with the virus.71 States are awarded three points for offering HIV
testing.72

Question 5—Does the state provide a preexisting arrangement for deliveries?
Having a preexisting arrangement to have the babies of incarcerated women delivered at a local hospital
reduces confusion and uncertainty when a woman goes into labor. Having an arrangement also allows
prisons to educate hospitals on any unwarranted security concerns that hospital staff may have and provide
an opportunity to address any concerns. States are given one point for making advance arrangements for
deliveries with local hospitals.

Question 6—Does the state provide advice on activity levels and safety?
Informing women of appropriate activity levels during the various stages of their pregnancy allows women to
request different work assignments, if necessary. Counseling on activity also provides administrative support for
women requesting any accommodation in their work schedules. Conversely, women who are pregnant should
not be unduly restricted in their ability to take certain work assignments if such restrictions are not medically
necessary or are made arbitrarily. States are awarded one point for providing advice on activity levels.

Question 7—Does the state require prisons to report all pregnancies and their
outcomes?
States that require prisons to report their pregnancy outcomes are taking an important step in insuring that
prisons are accountable. Collecting such data also helps a state indentify any systemic lapses in providing
appropriate prenatal care to pregnant women and taking steps to ensure that they have safe and healthy
deliveries. States that require such reporting receive one point.

Shackling During Labor and Delivery
Question 1—Does the state have a statute that explicitly restricts the Department
of Corrections’ routine use of restraints during labor and delivery?
Only six states have demonstrated a formal commitment to a woman’s civil and human rights by passing
laws that prohibit the routine use of restraints during labor and delivery. If any actor within the Department
of Corrections violates the law, women are afforded legal recourse and the opportunity to hold the state
accountable for its misconduct. These states are awarded 20 points, and receive a grade of B. States with laws
that extend the prohibition of restraints to labor, delivery, and post-delivery receive 25 points and a grade of A-.
None of the states with statutes have every one of the components we grade below in questions three through
seven: training, reporting on the use of restraints, uniform determination of security risk by the warden,
medical staff input, and consequences for improper use of restraints. This is because most of the statutes were
enacted fairly recently, so specific regulations and procedures addressing these issues may not have yet been
adopted. Information on these statutes can be found on page 18.

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Question 2—If the state does not have a statute, does the Department of
Corrections have a written policy that adequately limits the use of restraints on
pregnant women?
Women who are being transported to the hospital to give birth pose little, if any risk of escaping. They are
barely able to walk, let alone run or attempt escape routes. When pregnant women are being transported,
in labor and delivery, or post-delivery, they are under the constant surveillance of at least one officer. There
is no security justification for the routine use of restraints on a pregnant woman at any time during her
transportation to the hospital, or during her labor, delivery, and postpartum recovery.82
A written policy prohibiting the use of restraints—including handcuffs, leg irons or waist chains during
transport, labor, delivery, and post-delivery—receives ten points.83 Only Wisconsin and the District of Columbia
have written policies prohibiting the use of restraints during transport, labor, delivery and post-delivery.
Other states with written policies limiting restraints also receive points for their efforts at reducing risks to
pregnant women. These states at least recognize that it is unnecessary to place women in danger by restraining
them in certain ways at various times during the birthing process. Handcuffs pose a lesser risk to a pregnant
woman, so the use of handcuffs either during transportation or postpartum better reflects the important health
concerns of dealing with a pregnant woman. States that restrain women with handcuffs during one of these two
times, but forbid the use of handcuffs during labor and delivery receive six points. States that restrain women
with handcuffs at both of these times, but forbid the use of handcuffs during labor and delivery receive four
points.
States receiving a score of zero on Question 2 for not having a written policy
Each state should have a written and publicly accessible policy that limits the use of restraints on pregnant
women. Using restraints, including handcuffs, leg irons and waist chains, possibly endangers both a pregnant
woman and her unborn baby. It is therefore imperative for states to have formalized policies and procedures
in place to address under what limited circumstances restraints can be used when a woman is pregnant. When
policies are in writing, every member of the prison staff is more likely to possess knowledge of the policy. A
shared knowledge of formal policy contributes to uniformity in practices and procedures. Written policies
may also be referenced for clarification by prison officials and staff when there is a dispute. While some states
have expressed that they have an informal protocol regarding the use of restraints on pregnant women, without
a documented policy implemented statewide, there is little to ensure proper adherence to procedures that
minimize the risks to pregnant women. If a state does not have a written policy, it receives a zero.
States receiving a score of zero on Question 2 for having an inadequate written policy
Moreover, merely having a written policy on the use of restraints is not adequate. If the policy does not provide
any guidance as to when the use of restraints should be limited, the policy is wholly ineffective in advancing the
health of the pregnant woman and her unborn child. There are several types of DOC policies that restrict the
use of restraints but are nonetheless graded with a zero for this question.
If a state allows a pregnant woman to be restrained, there are certain times that pose an unacceptable threat
to the well-being of the woman and her unborn child. At no time should restraints be used during labor or
delivery because of the serious and potentially deadly consequences to the woman and her baby. States with
policies that allow any type of restraint to remain on during labor and/or delivery receive a zero.
In examining the types of restraints used, restraints must not constrict a pregnant woman, especially in her
abdomen area, nor hinder her ability to appropriately labor. For these reasons, waist chains and leg irons should
never be used on a pregnant woman during labor and delivery. Since leg irons and waist chains can be very
dangerous for women when they are adjusting to the additional weight and different center of gravity that
come with pregnancy, such restraints must also not be used during transport or post-delivery recuperation. State
policies that allow the use of these especially dangerous restraints on pregnant women at any time receive a zero.
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Question 3—Does the state require training for individuals handling and
transporting incarcerated persons needing medical care or those dealing with
pregnant women specifically?
Each state should have specialized training for correctional officers responsible for the handling and transport
of pregnant women, especially during labor and delivery. Incarcerated pregnant women pose specific challenges
and correctional officers should have specialized training to effectively and appropriately deal with the range
of scenarios that arise during pregnancy and the birthing process. In a survey conducted by the National
Institute of Corrections (NIC), in focus-group interviews with managers and other prison personnel, results
demonstrated numerous difficulties in trying to modify prison policies created for men when working with
women.84
An officer that has not been trained in working with pregnant women may panic in an emergency because
he or she is unfamiliar with what is to be expected. Conversely, an untrained officer may fail to recognize and
respond to what could be a serious health-related emergency. State departments of corrections need to provide
training for correctional officers to address the challenges of dealing with and transporting pregnant women
and women who have just given birth. If a state requires such training, it receives one point.

Question 4—Does the state have a high-level official responsible for determining
whether a pregnant woman poses a security risk and needs to be restrained?
State departments of corrections need to uniformly apply policies regarding the use of restraints. Many of the
policies examined permit the use of restraints on a pregnant woman if she seems to pose a substantial risk to
herself, her child, or others around her. It is most desirable to have one person, preferably at the highest level
of authority, responsible for determining whether a woman is a security risk to ensure uniformity, consistency,
and accountability. The best person to decide when a pregnant woman is a security risk is the warden or
director,85 to ensure uniformity and review by the highest authority within the prison. States that require
the warden or director to determine that restraints are necessary due to the security risk posed by a pregnant
woman receive two points. Full credit is also given to states that make an assessment of a woman’s security risk
at the time she enters the facility, and bases the use of restraints on that assessment.86
A far less appropriate person to discern whether a pregnant woman poses a security risk is a captain or
shift supervisor. Although a captain or shift supervisor is relatively high in the chain of command, because
there are multiple captains and shift supervisors, there is less uniformity and consistency when this is the
person responsible for determining whether a pregnant woman presents a security risk. States that leave
the determination to captains and shift supervisor receive one point. Some states allow any officer to make
the decision regarding the use of restraints on pregnant women. Since the use of restraints poses a potential
danger to the life and health of the pregnant woman and her unborn child, there must be uniformity and
accountability for the decision. This cannot be ensured if any officer has the authority to deem a woman a
security risk. If a state falls into this category, it receives a zero.

Question 5—Does medical staff have input on the decision to use restraints and/or
what type of restraints are used?
Even if a pregnant woman is deemed to be a security risk, the warden/director is not medically trained to
evaluate what is best for the pregnant woman. The policy should therefore require that a qualified medical
professional (internal or external) provide a medical assessment regarding what restraints to use to minimize
the risk of harm to a woman and her fetus, given her stage of gestation.87 No other prison official can make
an educated determination regarding the proper balance of protecting the woman, others around her, and the
unborn child. If a state requires prison authorities to seek input from medical staff when making the decision
to use restraints on a pregnant woman the state is awarded two points.88
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Question 6—Does the state require each incident where restraints are used to be
reported and reviewed by an independent body?
Incidents involving the use of restraints on pregnant women should be reviewed by an impartial third party,
commission, or taskforce. Third-party oversight is necessary to ensure that restraints are used in accordance
with the written policies. If a pregnant woman is restrained, there should be a mechanism for review to ensure
that state DOC policy was followed. The review should ensure that the use of restraints was appropriate, and
that the least restrictive restraints required by the situation were used.
Moreover, this review should not be limited to instances where there was the use of force. If the use of force
is required for an incident to be reviewed, then many cases involving the impermissible use of restraints might
escape review. If a state requires independent review of all cases where restraints are used the state is awarded
one point.

Inmates go to court to stop inhumane practices
Early in 2009, 22-year-old Joan Laurel Small was an inmate of Collier County Jail located in Naples,
Florida. Small complained for nearly two weeks that she was leaking amniotic fluid, but was ignored by
Prison Health Services. The fetus died when its skull collapsed while in utero.89 The prison also failed to
promptly arrange to have the fetus removed from Small, placing her at risk for infection, infertility and
even death. This incident exposed a whole host alarming health conditions for women imprisoned at the
Collier County Jail: inmates shackled to hospital beds during labor; a pregnant woman with gestational
diabetes going weeks without testing and treatment; and an inmate forced to deliver in a prison dropoff area after law enforcement ignored the woman’s complaints of labor contractions for hours.90 The
American Civil Liberties Union of Florida has requested that Collier County Jail disclose how many
inmates have reported miscarriages and stillborn babies as well as the facility’s policies for pregnant
inmates.91
Over the last few years, inmates across the country have filed lawsuits against Prison Health Services
related to the denial of medical care.92 Courts across the country are holding prisons and jails accountable
for their inhumane practices. The Federal Court of Appeals for the Eighth Circuit recently condemned
the practice of shackling in a case involving the civil rights of a pregnant inmate who was shackled to a
bed during hours of contractions.93 Other inmates have settled their lawsuits with Prison Health Services
for millions of dollars in damages based on the facility’s of failure to provide medical care to pregnant
women, including women who were forced to give birth over a prison cell toilet and fetal deaths caused
by delayed medical attention in prisons.94

Question 7—Does the state’s policy include consequences for individuals and/or
institutions found to be in violation of state policy regarding the use of restraints?
There should be prescribed consequences for individuals and/or institutions found to have violated state
policy regarding the use of restraints on pregnant women. If it is determined that the use of restraints was
not justified, or that the level of restraint was not the least restrictive required for the situation, violators
should be subject to repercussions, including reprimands, warnings, demerits, or mandatory training. This also
increases the likelihood that individuals and institutions will use more caution when deciding whether and
which restraints are warranted, and, once again, ensures the uniform application of policies. Consequences for
violating the policy regarding the use of restraints should be clearly outlined to ensure that any violations are
handled in the same manner, every time. Here, any state that has established consequences for policy violations
receives one point.

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Family-Based Treatment
as an Alternative to
Incarceration

Tamar Village Program Provides
Comprehensive Family-Based
Treatment96

Question 1—Does the state have a
family-based treatment program?
Family-based treatment allows mothers and children
to stay together in a healthy and healing therapeutic
community. Documented outcomes include improved
family stability, developmental progress among the
children, and lowered maternal recidivism rates.95
Mothers and children are given a safe environment
in which to address and heal addiction issues, such as
domestic violence and neglect that have a harmful
influence on the mother-child relationship. A state
that has a family-based treatment program receives
five points.

Question 2—Does the state allow
mothers to be sentenced to familybased treatment programs as an
alternative to incarceration?
States have the option to allow mothers to be
sentenced to family-based treatment programs as
alternative to incarceration. Examples of such statedirected collaborative efforts between DOCs and
family treatment programs have been supported by
state and federal funding streams. These alternative
sentencing programs allow mothes to remain in
a supervised and structured community instead
of being incarcerated. Because mothers who are
incarcerated are far more likely to be convicted of
non-violent crimes, their sentencing to a communitybased facility poses little danger to the public. Women
are better able to integrate into the community,
learn how to live on their own, and gain skills such
as financial management and job training. Children
also benefit from interacting with their mothers in a
community setting rather than in a prison. They can
visit in an environment that is far more conducive to
family life. States that allow mothers to participate in
family-based treatment programs in lieu of going to
prison receive five points.

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Started in October 2007, the SHIELDS for
Families’ Tamar Village Program provides
comprehensive family-centered substanceabuse treatment services to mothers reentering
the community from the criminal justice
system. Tamar Village grants these mothers the
opportunity to be reunited with their children
post-incarceration, and to care for their children’s
needs while obtaining important follow-up and
social services at an on-site apartment complex.
The apartment complex, equipped with office
space dedicated for treatment and other services,
also acts as transitional housing for the mothers
when they have completed treatment.
The Tamar Village program is designed to provide
treatment that will achieve safety, permanency and
well-being for the children and mothers, as well
as enhance service capacity in the community.
Based on an existing evidence-based model,
clients of Tamar Village attend services Monday
through Friday from 8:30 a.m. to 5:00 p.m. These
services include educational groups (health and
nutrition, HIV/AIDS, life skills, relapse prevention
for addiction), parenting and child development
classes, and therapeutic groups (trauma, grief
and loss, domestic violence, sexual abuse and
relationships). There is also an on-site child
development center for children ages 0-5 and a
youth program for children ages 6-18.
Part of what helps make Tamar Village successful
is its regional partnership with the Los Angeles
County Department of Children and Family
Services, the Los Angeles Sheriff ’s Department,
the Los Angeles County Public Defender’s Office,
the Los Angeles County Alcohol and Drug
Program Administration and the Corporation for
Supportive Housing. Through these collaborative
partnerships, Tamar Village ensures that mothers
successfully return to their communities postincarceration, and reunite with their children in
the context of a healthy and stable family-centered
treatment environment. As a result, mothers are less
likely to return to prison or lose their children to
the foster care system.

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Prison Nursery Programs
Question 1—Does the state offer mothers access to a prison nursery program?
While presenting a far less desirable option than alternative sentencing, which allows mothers to avoid
incarceration altogether, prison nurseries still present an opportunity for mothers and children to be together,
and are therefore at least worth mentioning among state’s efforts to meet the needs of parenting women.
Prison nurseries allow incarcerated mothers the option to give birth and bond with their children in ways
that are not possible solely through visitation. In these programs, mothers are given the opportunity to nurse
their children, and enjoy the beginning of their babies’ lives. Mothers also take classes and attend programs that
improve their child-rearing skills in anticipation of their eventual release from prison. Studies have shown that
a mother’s participation in a prison nursery program greatly improves her chances of rehabilitation once she is
released from prison.97
At the same time, prison nursery programs improve children’s outcomes. Babies born into prison nursery
programs are permitted the time and space to form close bonds with their mothers, so they do not suffer from
attachment disorders or other developmental difficulties caused by early separation from a caregiver. These
programs help children fulfill important developmental and emotional milestones.98 A state with a prison
nursery program receives one point.

Question 2—Does the state have a community-based prison nursery program?
A community-based nursery program allows mothers to have the benefits of bonding with their children
while not having this occur behind prison walls. These programs are similar to half-way houses, but they
specifically serve women and their newborns, and women may still be returned to prison to finish their
sentences once they leave the program. Although these women are still under correctional supervision, a
community-based program is far better situated to serve the unique physical and emotional needs of a mother
and her child, as compared to a program that is located within a prison.99 If a state has a prison nursery
program which is community-based, it receives one point.

Question 3—Does the state allow the child to remain in the prison nursery program
for a reasonable period of time?
The longer the length of time a mother and child can spend together, the more significant the bond and
the better the outcome for the relationship.100 In longer prison nursery programs, a mother has the time to
experience more developmental stages and nurture her child’s maturation. If a state’s nursery program allows a
child and mother to stay together for more than two years, the state receives three points. If a child can stay for
one to twenty-four months, the state receives two points. If a state allows a child to stay for up to thirty days, it
receives one point.

Question 4—Does the prison nursery program provide therapeutic services for
mother? For child?
Many mothers in prison have histories of abuse and trauma, and are at risk of continuing the cycles of abuse
and trauma with their children.101 An effective prison nursery program facilitates the health and healing of both
the mother and child. Intervention services offered might range from treating substance abuse, mental health
disorders, or domestic violence. Therapeutic services for the child can include an assessment for developmental
delays, therapeutic play, and intensive counseling. These therapeutic services are provided with the underlying
goal of healing and improving the relationship between a mother and her child. A state receives one point if its

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prison nursery program provides therapeutic services for the mother or the child. A state receives two points
for providing services to both mother and child.

Question 5—Does the program place any focus on improving the mother-child
relationship?
An effective prison nursery program should seek to improve the relationship between mothers and their
children, hence improving outcomes for family well-being and stability.102 A prison nursery program should do
more than let a mother and her child reside together; it should place a focus on developing their relationship.
A state receives one point if its prison nursery program focuses on improving the relationship between mother
and child.

Bedford Hills, New York: Setting the Standard for Prison Nurseries
The Bedford Hills Correctional Facility for Women includes the longest standing continuous prison
nursery in the country. This nursery has served as a model for many other prison nursery programs. In
1930, Governor Franklin D. Roosevelt signed a bill into law that allowed women in New York prisons
and reformatories to keep their babies with them for twelve to eighteen months following birth. The
Bedford Hills nursery program has operated within the medium and maximum security prison since that
time, and now has the capacity to support twenty-nine mothers and their babies.103
While there is little reason for these non-violent women to be imprisoned at all, this program nonetheless
should be commended for providing an opportunity for bonding between mothers and their children
during an important time in babies’ development. After their first year in the nursery, babies are placed
with relatives or foster parents. Bedford Hills provides women with a continuum of physical, mental,
and emotional support through its prenatal care, parenting center, infant day care center, child advocacy
office,104 and access to a GED-preparation program designed specifically for mothers and pregnant
women.105 The prison nursery program is also associated with the Bedford Hills Children’s Center, which
supports distance-parenting through various programs, including a developmentally appropriate visiting
area.106

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FEDERAL POLICIES AND RECOMMENDATIONS
FOR IMPROVEMENT
While the majority of women who are imprisoned are in state facilities, there are also a significant number
of women in federal custody. This includes both federal prisons and Immigration and Customs Enforcement
(ICE) detention for those who have been charged with violating immigration laws.
Largely due to mandatory sentencing for those convicted of drug offenses,107 the number of women
incarcerated in the Federal Bureau of Prisons (BOP) system increased from 1,400 to over 9,000 between 1980
and 1998.108 There were 13,746 women in Federal BOP custody as of June 2009, according to the most recent
data available.109 Approximately 56% of these women have children.110 Because there are only twenty-eight
federal facilities for women, most women are too far from their families to receive regular visits.111
The number of people being held in detention for violation of immigration laws has also increased
dramatically, primarily due to the Homeland Security Act of 2002.112 Passed in response to the terrorist
attacks of September 11, 2001, the law abolished the Immigration and Naturalization Service, and created the
Department of Homeland Security. The Act also strengthened federal authority to detain and deport those
found to be in the country illegally, and created ICE to carry out this function. The number of individuals
detained rose almost 50% between 2005 and 2008.113 As of September 1, 2009, women comprised about 9%
of the 31,075 individuals in detention.114 As one report noted, the current standards governing ICE facilities
are not actual statutes or regulations, making it difficult for those working on behalf of detainees to demand
accountability for upholding the standards.115 Advocates are urging the Department of Homeland Security to
provide further protections for detainees in its planned overhaul of the detention system.116
It appears that the federal government has made minimal efforts to meet the needs of pregnant and parenting
women who are incarcerated or detained in federally operated facilities. Far more remains to be done to
protect the rights and ensure the health and well-being of these vulnerable populations.
Furthermore, the federal government plays an important role in making funds available to states. States can
apply for federal funding to adopt programs that they may not otherwise initiate on their own. The federal
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government can also exercise its authority over states by withholding funding when the states do not meet
certain federal requirements regarding prison conditions or programs.
This section summarizes some of the federal laws, regulations and policies that play an important role in
protecting the health and lives of pregnant and parenting women in custody in both federal prisons and ICE
facilities, and provides an assessment of how the Federal government is currently meeting the needs of these
vulnerable populations. This section also examines some policy efforts the Federal government has made to
improve conditions in state facilities as well. Finally, we provide some recommendations for improvements in
each of these areas.

PRENATAL CARE
Federal Bureau of Prisons
Federal regulations require that a pregnant woman be provided with “medical, case management, and
counseling services” and that the facility make arrangements for her to give birth in a hospital.117 Regulations
also require that pregnant women be given access to resources to facilitate the placement of their newborns in
appropriate homes.118 While information on the actually delivery of health care to pregnant women who are
imprisoned is sparse, a report by the National Association of Women Judges reveals that health care for women
in federal prisons, including pregnant women, is “unacceptable.”119 The report specifically cites problems with
access to prenatal care.

Immigration and Customs Enforcement Detention
The ICE policy regarding pregnancy states “female detainees shall have access to pregnancy testing and
pregnancy management services that include routine prenatal care, addiction management, comprehensive
counseling and assistance, nutritional, and postpartum follow-up.”
It appears that every woman is given a pregnancy test when she enters detention, but while some detainees
report prompt pregnancy care, others face bureaucratic hurdles to receiving the most basic services and
experience substantial delays in access to prenatal care.120 For example, a detainee reported difficulty in getting
access to prenatal vitamins, or proper monitoring of an ovarian cyst that could have posed serious pregnancy
complications.121 A detainee who was seven months pregnant reported that she could not feed her other
children and eat her own meals within the twenty minutes allotted, and she was not allowed to take food with
her.122
According to a recent report by Human Rights Watch (HRW),123 ICE has taken significant steps to improve
policies regarding pregnancy-related care, but problems remain with consistent implementation of the policies.
Serious lapses in policy also remain. Because ICE contracts with private companies or local jails, often
detainees are not afforded the benefits of good ICE policies.124

Improving State Policies
The federal government does not provide funds to the states to improve health care for pregnant and parenting
women in state custody, nor is it using its funding powers to encourage states to enhance access to high-quality
health services for women who are pregnant.
One way to enhance access to health care for pregnant women in custody would be for Congress to repeal the
“inmate exception” to the Social Security Act.125 This section of the Social Security Act, 42 U.S.C. §1396d(a),
forbids states from receiving matching funds for services provided to incarcerated persons who are otherwiseeligible recipients of Medicaid. Allowing states to receive federal matching funds for services provided to
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incarcerated pregnant women would provide an incentive for states to provide prenatal care, and would
improve pregnancy outcomes among this vulnerable population.

SHACKLING
Federal Bureau of Prisons
In October 2008, the Federal Bureau of Prisons revised its policy regarding the shackling of pregnant women
in their custody.126 The policy states in relevant part:
Restraints should not be used when compelling medical reasons dictate, including when a pregnant prisoner is in labor,
is delivering her baby, or is in immediate post-delivery recuperation.
...
If a pregnant prisoner is restrained, the restraints used must be the least restrictive necessary to ensure safety and
security. Any restraints used must not physically constrict the direct area of the pregnancy.
In addition to this policy, Section 232 of the Second Chance Act also requires the Attorney General to report
to Congress on the use of physical restraints on pregnant prisoners by agencies within the Department of
Justice (DOJ).127 The Bureau of Prisons is an agency within DOJ, and would thus be required to report data
regarding the use of restraints to the Attorney General. Data collection will be an important component of
enforcement of the BOP’s policy on the use of restraints on pregnant women.

Immigration and Customs Enforcement Detention
ICE allows restraints to be used on pregnant detainees, but requires that detention officers consult with
medical staff “before deciding the situation is grave enough to warrant the use of physical force.”128 Despite a
policy that should protect pregnant detainees, advocates have received reports indicating that pregnant women
are shacked in violation of these guidelines and without adequate justification. There are reports of a detainee
who was six months pregnant being shackled while on her way to and from prenatal visits, despite the fact
that she posed no risk of danger or escape.129 Shackles are also routinely used on pregnant women during
transport.130
The U.S. Department of Homeland Security has not been responsive to advocates’ request that ICE clarify
existing procedures and develop and implement consistent guidelines on the use of restraints. Advocates will
continue to urge clarification of this policy, although the current set of recommendations does not address the
use of force and restraints.131
The Second Chance Act requires ICE to report on its use of restraints to the Department of Justice, which will
hopefully spur the agency to clarify its policies.132

Improving State Policies
At this time, the federal government is not using its funding powers to encourage states to restrict the use
of shackling of imprisoned women who are in labor or delivery, or requiring states to report their use of
restraints.
BOP could recommend that its policy be adopted by all state departments of corrections. Although this
recommendation would not have the force of law, it would encourage states to treat pregnant women who are
incarcerated humanely, and assuage concerns that limiting the use of restraints poses security risks.

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Furthermore, DOJ could prosecute the improper restraint of pregnant women as a violation of the Civil
Rights of Institutionalized Persons Act (CRIPA). CRIPA allows the Attorney General to bring civil suits
challenging state prison conditions that violate the constitutional rights of people who are incarcerated.133
The Department of Justice could also issue a statement reminding states that shackling during labor and
delivery is a violation of the Eighth Amendment right not to be subjected to cruel and inhumane punishment,
indicating both its jurisdiction and willingness to prosecute states for offenses.134 A federal court has also
declared that prison officials may be found to have violated the Eighth Amendment when, without a sufficient
safety justification, they act with “deliberate indifference to the inmate’s health and safety,” or take actions that
cause “unnecessary suffering,” lending further support to DOJ action on the issue.135

ALTERNATIVES TO INCARCERATION
Federal Bureau of Prisons
The federal criminal justice system makes alternative sentencing available based on the type of crime and
characteristics of the person being sentenced. Federal alternative sentencing consists of three options: a
combination of prison and community confinement (a treatment center of halfway house or other supervised
residential facility), community confinement with probation, or probation only.136 Of the 4,328 women
eligible for alternative sentencing in 2007, eighty-seven percent received a sentence other than prison only.137
These high rates of alternative sentencing indicate that judges recognize female offenders pose no threat to
their communities.
Nonetheless, because people convicted of crimes carrying mandatory minimums, including many drug
offenses, are ineligible for alternative sentencing,138 many non-violent women facing their first conviction are
sentenced to prison.139
Judges are also permitted to reduce prison sentences based on “extraordinary and compelling reasons”
including the need to care for minor children.140 The sentencing guidelines, however, explicitly state that
family ties and responsibilities do not warrant a departure from the sentencing guidelines.141
In addition to incarceration alternatives that are generally available, the Community Corrections Branch of the
Bureau of Prisons established the pilot program, Mother and Infant Nurturing Together (MINT), in 1990.142
The program’s goals are to promote bonding and provide parenting skills to women who will eventually
have custody of their children when their prison terms are over. MINT allows women who are in their last
trimester of pregnancy to live in a community-based facility that contracts with the BOP. The usual length
of participation is three months after giving birth, though some programs allow mothers more time to bond
with their children.143 Before entering the program, women must arrange for a caretaker for their children. A
woman who enters the program close to the end of her sentence may be released to a halfway house instead of
returned to the BOP facility.
Most programs require that women have less than five years left on their sentences, though some programs
allow women with longer sentences to participate.144 Women are evaluated for participation based on their
health, behavior record and risk to the community in which they are placed. After a successful pilot program
in Fort Worth, Texas, the program was expanded.145 One study of programs in New York City and St. Louis
showed that only ten percent of those who successfully completed the program returned to prison.146 While
there are now seven MINT sites around the country, with the capacity for only fifty-nine mother/infant
pairs,147 more women within the BOP system should have the opportunity to establish bonds with their
newborns. The success of the program was established in the initial pilot program, and provides ample evidence
as to why it should be expanded further to accommodate more mothers.

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Immigration and Customs Enforcement Detention
While those charged with violating immigration laws are civil, and not criminal, detainees148 their detention
in an ICE facility closely resembles criminal confinement.149 ICE operates three programs allowing for
alternatives to detention, with varying restrictions and supervision depending on the detainee’s flight risk and
danger to the community. Conditions of release may include electronic monitoring, telephone check-ins,
periodic meetings with ICE officials and employment verification.150 There is no available information on how
often this alternative is currently granted to pregnant or parenting women, or how parental status is evaluated
in determining eligibility.
A 2007 report reviewing conditions in family detention centers and ICE policies noted, “Although there is
precedent in the adult detention system for the use of alternatives to detention and other pre-hearing release
systems, ICE has unfortunately made no effort to expand these programs to include families.”151
The recent review of ICE detention includes a recommendation for developing an assessment of flight risk
and danger to the community to better identify candidates for alternatives to detention. While pregnancy or
parenting status are not specifically included as factors, they would certainly be relevant in assessing a detainee’s
suitability to remain in the community.152 A pregnant woman may be deemed to have a reduced “propensity
for violence” based on her physical limitations. Likewise, a detainee might be less likely to flee based on strong
bonds with her minor children.
Human Rights Watch notes that ICE changed its policy to encourage its offices to parole all nursing mothers
who were statutorily eligible and did not pose risks to national security.153 Nonetheless, ICE has not managed
to implement this policy consistently, and HRW identified nursing mothers who were in fact detained.
Another investigation of ICE practices revealed that the “government routinely fights [immigration attorneys’]
efforts to get pregnant detainees released on bond.”154

Improving State Policies
The Second Chance Act allows states to apply for federal funding for states, tribal or local prosecutors to
establish or expand demonstration programs to reduce recidivism and improve reentry into the community
for those who are returning from prison. These funds can be used for alternative sentencing programs, which
allow mothers to remain in the community and be given an opportunity to develop a relationship with their
children.
While no state, tribal or local entity is required to apply for the funds or enact a program, given states’ tight
budgets, there is clearly an incentive for states to supplement their budgets with any available federal funds.
The Bureau of Justice Assistance, the agency that administers the Second Chance Act, could conduct some
low-cost outreach by highlighting grantee successes, reminding states of available funding and providing
technical assistance with states’ applications.

PRISON NURSERIES
Federal Bureau of Prisons
The BOP does not operate prison nurseries. Given that many mothers are not dangerous to their communities
and are better able to bond with their children while in community placement, we encourage the BOP to
expand the MINT program, rather than establish prison nurseries.

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Immigration and Customs
Enforcement Detention
Parents and children who are detained are
kept together,155 a major shift in policy
resulting from Congressional action in
2005.156 While immigration detention is not
supposed to be imprisonment, conditions of
confinement have been described as “prison
like” even in facilities specifically intended
to serve families. In August 2007, the ACLU
settled a lawsuit against the T. Don Hutto
Family Detention Center in Taylor, Texas,
resulting in improved privacy, increased
freedom of movement, better health care
and food, and more toys and books.157 The
ACLU continued to publicly advocate with
the Department of Homeland Security (DHS)
and Congress for Hutto’s closure. In August
2009, just weeks before the expiration of the
settlement, DHS announced that it would
close the family facility. No family remained at
Hutto after September 2009.
The House Committee on Homeland
Security noted that the “Department of
Homeland Security does not routinely make
Alternatives to Detention available to families
it takes into custody.”158 While commending
ICE for implementing standards for family
detention, the Committee expressed concern
that those standards were modeled on prison
standards.159 ICE has recently announced plans
to overhaul the detention system, including
how the system treats the minor children of
detainees.

Indiana Women’s Prison: Family
Preservation Program
This award-winning program160 began in 1996 as a
collaboration between the Indiana Women’s Prison, the
Indiana Department of Health’s Maternal Child Health
Services and the Division of Family and Social Services.
The Program provides extensive support for mothers to
maintain their relationships with their children despite
the barriers imposed by incarceration. Recognizing that
almost all incarcerated women will one day be reunited
with their children, families receive the tools they need
for a successful post-incarceration relationship.161 The
program added a nursery in 2008.
The Family Preservation Program includes individual
and family counseling to begin healing trauma caused by
histories of addiction, poverty, and mental, physical and
sexual abuse. Women who typically came to prison from
underserved communities—lacking access to adequate
housing, education or health care—are provided with
the information they need to access such services as they
prepare to leave prison and reunite with their families.
The program is funded through both public and
private donations, including substantial funding from
the Maternal and Child Health Bureau of the Health
Resources and Services Administration of the U.S.
Department of Health & Human Services.162 The
substantial investments made in this type of “wraparound” care are paying off. The prison had a recidivism
rate of just eight percent after the program had been in
effect for three years,163 as compared to a rate of thirtynine percent among a nation-wide sampling.164

Improving State Policies
Given that many mothers are not dangerous to their communities and are better able to bond with their
children while in community placement, the federal government should not use its funding powers to
encourage states to expand prison nursery programs. The federal government should continue to provide
funding to states to expand community-based sentencing, including increased funding under the Second
Chance Act. Furthermore, Section 243 of the Second Chance Act authorizes the Attorney General to identify
best practices within state departments of corrections that support the relationship between incarcerated
parents and their children. Any report on best practices should place an emphasis on community-based
sentencing for non-violent offenders, and highlight the special importance of family relationships in reducing
recidivism among women in the criminal justice system.

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Methodology
The primary goal of this state-by-state Report Card is to shed light on the current conditions faced by
pregnant women in prisons across the country. In order to better assess such conditions, the Report Card
delves into state policies relating to: Prenatal Care, Shackling, Family-Based Treatment as an Alternative to
Incarceration and Prison Nurseries.
The Prenatal Care section reviews policies regarding health care for pregnant inmates. This information is
derived from a report by the ACLU, which compares state policies to nationally recognized standards on health
care for imprisoned pregnant women issued by the National Commission on Correctional Health Care and
the American Public Health Association.165 The Shackling, Alternative to Incarceration, and Prison Nursery
portions compile information gathered from each state’s department of corrections’ (DOC) response to a series
of questions developed by the Rebecca Project and the National Women’s Law Center.
In order to obtain questionnaire responses, each state’s DOC was first contacted via telephone starting on June
8, 2009, by staff at the Rebecca Project. Initial contact was made by calling the provided number to the state
DOC as listed on the state’s website. In speaking to the person who answered Rebecca Project staff ’s calls, staff
was then either transferred or given the telephone number of someone who could answer questions about
“policy in prisons for female inmates.” Upon transfer, or when making the next call to the person with direct
knowledge on the issues to be covered by the questionnaire, staff introduced themselves and their reason for
calling by providing their name, affiliation with the Rebecca Project for Human Rights, and stating “I was
wondering if you could answer a few questions about policies in your prisons for female inmates?”
When asked about the purpose for the research, every state was told that the Rebecca Project was compiling
research on state policies in order to create a state report card to compare the policies of each state. The
questionnaire was then delivered either over the phone or submitted for completion via email throughout the
months of June, July and August, 2009.

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Points for each indicator within the
four areas were given based on the
relative importance of the particular
policy to improving health outcomes
and the overall well-being of pregnant
and parenting women and their
children, as explained for each policy.166
Each state is assigned a final letter grade
based on its total points as compared
to the highest possible score for that
indicator and its performance relative
to the other states’ performance in that
category.
Unfortunately, for unknown reasons,
many states did not respond. As a
result of the lack of responses from a
number of states, additional research
was conducted in order to gather
more comprehensive information on
state policies.167 Specifically, in the
Alternative to Incarceration and Prison
Nursery sections, information was
gathered from the Women’s Prison
Association study “Mothers, Infants,
and Imprisonment: A National Look
at Prison Nurseries and CommunityBased Alternatives.”168

Girl Scouts Beyond Bars
Girl Scouts Beyond Bars (GSBB) is a national program that
offers girls the opportunity to visit and maintain relationships
with their incarcerated mothers. GSBB originated in 1992
through a partnership between the Girl Scout Council of
Central Maryland and the U.S. Department of Justice’s National
Institute of Justice, and has since expanded to over thirty-seven
GSBB programs across the country.171 GSBB works to diminish
the negative effects of parental separation by offering women
and girls the chance to build, re-establish, and maintain motherdaughter relationships through regular visits and mentoring.
As part of the GSBB program, mother-daughter Girl Scout
troop meetings are held at the correctional facility and girl-only
troop meetings also take place in the community. GSBB is based
on building leadership and parenting skills among incarcerated
mothers, who often lead troop meetings and facilitate discussion
about topics relevant to the girls’ lives. The program is designed
to encourage self-esteem and positive decision-making among
girls under the age of eighteen,172 a demographic that has
become the fastest growing segment of the juvenile justice
population, despite an overall drop in juvenile crime.173 GSBB
also facilitates the transition of the mother-daughter relationship
once mothers are released into the community by continuing
to offer programs and maintaining contact with former
participants. This program serves approximately 800 girls and
600 mothers annually.174

The Alternative to Incarceration data
was collected through March and April
of 2010 by telephoning family-based treatment centers and asking to speak with a worker “familiar with the
center’s intake procedures.” Once this person was identified, Rebecca Project staff introduced themselves and
described the purpose of the Report Card. The intake personnel were then asked whether “mothers could be
sentenced to the treatment center in lieu of being sentenced to prison.”
Ultimately, scores were based on the information either provided to the Rebecca Project through its contacts
with the states, or on information that was publicly available. States are therefore penalized for either failing
to respond to our calls and surveys or to make their policies readily available. Incarcerated women represent
a highly vulnerable population. It is of critical importance that advocates, prisoners’ loved ones, lawmakers
and other stakeholders have a way to easily obtain information on the policies that govern these women’s
day-to-day lives.169 The existence of formal, written, and publicly available policies furthers institutional
accountability.170
Some states indicated that they could not disclose certain policies because of security concerns. The very fact
that so many other states were willing to disclose information, and saw no apparent threat to security, indicates
a lack of transparency on the part of these states without an adequate security justification.
We use an asterisk to indicate when a policy falls outside of the range of possibilities presented by our
question. This may mean that either: (1) the policy does not explicitly meet our criteria and we are awarding it
points because it meets the needs of pregnant or parenting women and their children, or (2) that it technically

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meets our stated criteria but something about the policy makes it ineffective in meeting its purported goals.
We provide more information on these particular states on page 18.
Zeros were used when research has shown that the state does not in fact have the specified program or
policy. Dashes were used when information could not be found through any of the means pursued: direct
conversation through phone or email with the state, independent research on state policies or research by
any outside source consulted. Dashes were also used when the official we spoke with could not confirm a
particular policy. In these cases, the lack of transparency results in a grade of F for the particular issue.
We encourage any state department of corrections official, legislator or other person with direct knowledge
of the policies examined in this report with additional or contradictory information to please contact us. We
welcome broad input and will issue an addendum reflecting any updated or additional policy information
regarding the treatment of pregnant and parenting women who are incarcerated.

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Endnotes
1

Women may also be confined to jails, which are generally for shorter term sentences. Jails are controlled locally, and are therefore beyond the scope of
this report.

The Report Card also includes an analysis of prison nurseries, but for reasons set forth below, did not include these programs in the states’ composite
grades.

For more information on data collection and analysis, please see the Methodology Section.

The Report Card also uses the term mother because these are women who have decided to continue their pregnancies to term and plan to give birth.
While some women may place their children for adoption, they remain birth mothers to their children.

Maeve McMahon, Is Assisting Female Offenders an Art or Science?, in Women and Girls in the Criminal Justice System: Policy Issues and Practice Strategies 2-1, 2-4
(Russ Immargieon ed., Civic Research Inst. 2006).

Julie Kowitz Margolies & Tamar Kraft-Stolar, When “Free” Means Losing Your Mother:The Collision of Child Welfare and the Incarceration of Women in New York
State 1, 4 (Corr. Ass’n of N.Y. Women in Prison Project 2006).

Lawrence A. Greenfeld and Tracy L. Snell, NCJ 175688, Women Offenders 1 (Bureau of Justice Statistics 1999).

Id.

10 Barbara Bloom, Barbara Owen & Stephanie Covington, Gender Responsive Strategies: Research, Practice, and Guiding Principles for Women Offenders 1
(Nat’l Inst. of Corr. 2003).
11 Jocelyn M. Pollack, A National Survey of Parenting Programs in Women’s Prisons in the U.S., in Women and Girls in the Criminal Justice System: Policy Issues and
Practice Strategies 19-1, 19-2 (Russ Immargieon ed., Civil Research Inst. 2006).
12 Julie Kowitz Margolies & Tamar Kraft-Stolar, When “Free” Means Losing Your Mother:The Collision of Child Welfare and the Incarceration of Women in New York
State 1, 9 (Corr. Ass’n of N.Y. Women in Prison Project ed., 2006).
13 Barbara Bloom, Barbara Owen & Stephanie Covington, Gender Responsive Strategies: Research, Practice, and Guiding Principles for Women Offenders 75-77
(Nat’l Inst. of Corr. 2003).
14 See generally Barbara Bloom, Barbara Owen & Stephanie Covington, Gender Responsive Strategies: Research, Practice, and Guiding Principles for Women Offenders
23 (Nat’l Inst. of Corr. 2003).
15 William J. Sabol, Heather C. West and Matthew Cooper, NCJ 228417, Prisoners in 2008 1 (Bureau of Justice Statistics 2009); King’s College London,
World Prison Brief, Highest to Lowest Rates,1 (Sept. 2009), available at http://www.kcl.ac.uk/depsta/law/research/icps/worldbrief/.
16 See Nelson v. Corr. Medical Serv., 583 F.3d 522, 525-26 (8th Cir. 2009) (pregnant woman shackled in final stages of labor and until moment of delivery
despite prison policy requiring security risk assessment before the use of restraints on inmates).
17 See Estelle v. Gamble, 429 U.S. 97, 104 (1976) (holding that “deliberate indifference” to the serious medical needs of the incarcerated constitutes “cruel and
unusual punishment” prohibited under the Eight Amendment to the Constitution).
18 Barbara Bloom, Barbara Owen & Stephanie Covington, Gender Responsive Strategies: Research, Practice, and Guiding Principles for Women Offenders 75-77
(Nat’l Inst. of Corr. 2003).
19 See, e.g., Flynn v. Doyle, 672 F.Supp.2d 858, 877 (E.D. Wis. 2009) (defendants, state corrections officials, conceded that incarcerated men have more
comprehensive mental health services than incarcerated women because of the “historically small number of female prisoners” in the state).
20 Nat’l Comm’n on Corr. Health Care, Position Statements,Women’s Health Care in Correctional Settings (rev. 2005), available at http://www.ncchc.org/
resources/statements/womenshealth2005.html.
21 Nicholas Freudenberg, Adverse Effects of U.S. Jail and Prison Policies on the Health and Well-Being of Women of Color, 92 Am. J. of Public Health 1895, 1896
(2002).
22 M. Knight & E. Plugge, The Outcomes of Pregnancy Among Imprisoned Women: A Systematic Review, 112 BJOG: An Int’l J. of Obstetrics & Gynecology 1467,
1473 (2005) (indicating better pregnancy outcomes for incarcerated women, as compared to similarly disadvantaged women not incarcerated; noting that
this result may be because “prison provides food and shelter, moderates the use of drugs and alcohol, prevents strenuous activity, protects women against
abusive partners and ensures access to antenatal care.” Findings do not reflect the quality of care received by women who are incarcerated, rather the
women’s dire circumstances of the non-incarcerated control group).
23 Nat’l Comm’n on Corr. Health Care, Position Statements,Women’s Health Care in Correctional Settings (rev. 2005), available at http://www.ncchc.org/
resources/statements/womenshealth2005.html.
24 Letter from Ralph Hale, Executive Vice President, American Coll. Of Obstetricians and Gynecologists, to Malika Saada Saar, Executive Director, The
Rebecca Project for Human Rights (June 12, 2007) (on file with author) (calling for an end to the practice of shackling women in labor and delivery due
to the potential harm posed to the woman and unborn child), available at http://www.acog.org/departments/underserved/20070612SaarLTR.pdf.
25 Fed. Bureau of Prisons, No. 5538.05, Program Statement, Escorted Trips (2008), available at http://www.bop.gov/policy/progstat/5538_005.pdf.
26 Cal. Penal. Code § 3423 (West 2009); An Act Concerning the Safe Treatment of Pregnant Persons in Custody, 2010 Colo. S.B. 193; 55 Ill. Comp. Stat.
Ann. 5/3-15003.6 (West 2010); N.M. Stat. Ann. § 33-1-4.2 (2010); N.Y. Correction Law § 611 (2010); An Act Amending Title 61 (Penal and Correctional
Institutions) of the Pennsylvania Consolidated Statutes, 2009 Pa. Laws 45; An Act Relating to the Use of Restraints to Control the Movement of Pregnant
Women and Female Children Confined in Certain Correctional Facilities in this State, 2009 Tex. Gen. Laws 1184;Vt. Stat. Ann. Tit. 28, § 801a (2010);
An Act Relating to the Use of Restraints on Pregnant Women or Youth, 2009 Wa. H.B. 2747; W.Va. Code § 25-1-16 (2010).

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27 Laura M. Maruschak, Medical Problems of Prisoners tbl.10 (Bureau of Justice Statistics 2008).
28 Adam Liptak, Prisons Often Shackle Pregnant Inmates in Labor, N.Y. Times, Mar. 2, 2006, at A16, available at http://www.nytimes.com/2006/03/02/
national/02shackles.html.
29 U.S. Marshals Service, USMS Directive 901 §D(3)(e)-(h) (revised policy on shackling pregnant offenders); Letter from Joyce Conley, Assistant Director,
Fed. Bureau of Prisons, to Richard Durbin, U.S. Senator (Oct. 17, 2007) (on file with The Rebecca Project for Human Rights).
30 Barbara Bloom, Barbara Owen & Stephanie Covington, Gender Responsive Strategies: Research, Practice, and Guiding Principles for Women Offenders 56
(Nat’l Inst. of Corr. 2003).
31 Barbara Bloom, Barbara Owen & Stephanie Covington, Gender Responsive Strategies: Research, Practice, and Guiding Principles for Women Offenders 7
(Nat’l Inst. of Corr. 2003).
32 Anthony C. Thompson, Releasing Prisoners, Redeeming Communities Reentry, Race, and Politics 64-65 (NYU Press 2008).
33 Barbara Bloom, Barbara Owen & Stephanie Covington, Gender Responsive Strategies: Research, Practice, and Guiding Principles for Women Offenders 57
(Nat’l Inst. of Corr. 2003).
34 Ctr. for Substance Abuse Treatment, RWC/PPW Cross-site Evaluation, Factsheet 9, Client Outcomes (Caliber Assocs. 2003).
35 Id. at 1-2.
36 Susan Phillips, Mother-Child Programs: Connecting Child Welfare and Corrections Agencies, in Women and Girls in the Criminal Justice System: Policy Issues and
Practice Strategies 22-1(Russ Immargieon ed., Civic Research Inst. 2006); Julie Kowitz Margolies & Tamar Kraft-Stolar, When “Free” Means Losing Your
Mother:The Collision of Child Welfare and the Incarceration of Women in New York State 1, 8 (Corr. Ass’n of N.Y. Women in Prison Project 2006).
37 Julie Kowitz Margolies & Tamar Kraft-Stolar, When “Free” Means Losing Your Mother:The Collision of Child Welfare and the Incarceration of Women in New York
State 1, 27 (Corr. Ass’n of N.Y. Women in Prison Project 2006).
38 Id.
39 Barbara Bloom, Barbara Owen & Stephanie Covington, Gender Responsive Strategies: Research, Practice, and Guiding Principles for Women Offenders 7
(Nat’l Inst. of Corr. 2003).
40 Julie Kowitz Margolies & Tamar Kraft-Stolar, When “Free” Means Losing Your Mother:The Collision of Child Welfare and the Incarceration of Women in New York
State 1, 20 (Corr. Ass’n of N.Y. Women in Prison Project 2006).
41 Jocelyn M. Pollack, A National Survey of Parenting Programs in Women’s Prisons in the U.S., in Women and Girls in the Criminal Justice System: Policy Issues and
Practice Strategies 19-1, 19-4 (Russ Immargieon ed., Civil Research Inst. 2006).
42 Julie Kowitz Margolies & Tamar Kraft-Stolar, When “Free” Means Losing Your Mother:The Collision of Child Welfare and the Incarceration of Women in New York
State 1, 9 (Corr. Ass’n of N.Y. Women in Prison Project 2006).
43 Kelsey Kauffman, Prison Nurseries: New Beginnings and Second Chances, in Women and Girls in the Criminal Justice System: Policy Issues and Practice Strategies
20-1, 20-6 (Russ Immargieon ed., Civil Research Inst. 2006).
44 Id. at 20-3 to -4.
45 Id. at 20-6.
46 Id.
47 Lorie Smith Goshin & Mary Woods Byrne, Converging Streams of Opportunity for Prison Nursery Programs in the United States, 48 J. of Offender
Rehabilitation 271, 275 (2009).
48 Ill. Dep’t of Corr. Overview, Women and Family Serv., http://www.idoc.state.il.us/subsections/dept_overview/dept_overview.shtml.
49 Press Release, Ill. Dep’t of Corr., Ten-Year Anniversary of IDOC’s Women and Family Services Division Focuses On Best Practices As Well As Gender
Responsive Services and Reentry Management for the Female Offender (May 12, 2009) (on file with author).
50 Id.
51 Barbara Bloom, Barbara Owen & Stephanie Covington, Gender Responsive Strategies: Research, Practice, and Guiding Principles for Women Offenders 11
(Nat’l Inst. of Corr. 2003).
52 Press Release, Ill. Dep’t of Corr., IDOC Officially Opens Moms and Babies Program at Decatur Correctional Center (May 10, 2007) (on file with
author) (citing May 2004 study by the National Resource Center for Foster Care and Permanency Planning at the Hunter College School of Social
Work), available at http://www.idoc.state.il.us/subsections/news/ (follow “DOC Press Archive” hyperlink; then follow “2007” drop down; then follow
“May 10, 2007” hyperlink).
53 Moms and Babies—First Anniversary, Jan. 2009 Newsletter (Ass’n on Program for Female Offenders, Chicago, Ill.) Jan. 2009, available at http://www.
apfonews.org/page_three.htm.
54 Id.
55 Id.
56 Jeff Kelly Lowenstein & Christiana Schmitz, Not a Priority, Chicago Reporter, Sept. 2, 2008, available at http://www.chicagoreporter.com/index.php/c/
Cover_Stories/d/Not_A_Priority.
57 Press Release, Ill. Dep’t of Corr., Ten-Year Anniversary of IDOC’s Women and Family Services Division Focuses On Best Practices As Well As Gender
Responsive Services and Reentry Management for the Female Offender (May 12, 2009) (on file with author).
58 Id.

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59 Dep’t of Corr., Children of Incarcerated Parents Project, http://www.oregon.gov/DOC/TRANS/PROGMS/oam_children.shtml.
60 Parenting Inside Out, Curriculum, http://www.parentinginsideout.org/curriculum (last visited Jan. 15, 2010).
61 J. Mark Eddy et al., Development of a Multisystematic Parent Management Training Intervention for Incarcerated Parents,Their Children, and Families, 12 No. 3
Clinical Psychologist 86 (2008).
62 E-mail from Mindy Clark, Director of Marketing & Communications, Children’s Justice Alliance, to Grace Lesser, Health & Reproductive Rights
Program Assistant, National Women’s Law Center (Jan. 14, 2010, 5:45 EST) (on file with the National Women’s Law Center).
63 This section of the Report Card is based on data from the ACLU Report, State Standards for Pregnancy-Related Health Care in Prison (2008), available at
http://www.aclu.org/reproductiverights/gen/pregnancycareinprison.html. While ACLU’s data is used with the organization’s permission and ACLU staff
has assisted in developing grades, the ACLU’s report did not attempt to assign grades. We have also confirmed that the states receiving an F grade for not
reporting data have not made data publicly available since the publication of the ACLU report.
The ACLU report also includes information on state’s policies regarding counseling women on their pregnancy options. Since the scope of this report
is limited to policies regarding women in prison who choose to continue their pregnancies, we did not include the ACLU’s information regarding state
policies on their legally protected right to terminate a pregnancy.
64 March of Dimes, Prenatal Care, http://www.marchofdimes.com/pnhec/159_513.asp.
65 Id.
66 March of Dimes, Nutrition Today Matters Tomorrow (March of Dimes Task Force on Nutrition and Optimal Development ed., 2002), available at
http://www.marchofdimes.com/professionals/1926.asp.
67 Nat’l Comm’n on Corr. Health Care, Position Statements,Women’s Health Care in Correctional Settings (rev. 2005), available at http://www.ncchc.org/
resources/statements/womenshealth2005.html.
68 Id.
69 Id.
70 We were unable to obtain specific state-by-state information on the provision of HIV treatment. Despite the Eighth Amendment guarantee of medical
care for serious medical conditions, see infra p.#, the prison setting poses serious barriers to all medical care, including the prompt, confidential delivery
of time sensitive antiretrovirals used to control viral loads in those with HIV. Segregating prisoners with HIV was one thought to advance medical
care, with institutions giving little thought to the privacy violation, stigma and danger that segregation might pose to those with HIV. Mary Sylla, HIV
Treatment in U.S. Jails and Prisons, The Body, Winter 2008, http://www.thebody.com/content/art46432.html.
71 “Data indicate that when appropriate antiretroviral medications are given during pregnancy, labor, and delivery and after birth, the risk of transmission can
be reduced no less than two percent compared with approximately twenty-five percent when no interventions are given.” Centers for Disease Control
and Prevention, Perinatal HIV Transmission, http://www.cdc.gov/hiv/topics/perinatal/overview_partner.htm#transmission.
72 HIV testing should not be mandatory because of serious privacy and informed consent concerns. States are only credited for offering testing. Oklahoma
appears to make the test mandatory, and therefore, is not awarded credit. Okla. Dep’t. of Corr., MSRM-140145-01, Management of Pregnancy (2008),
available at http://www.doc.state.ok.us/treatment/medical/msrm/140145-01.pdf.
73 Maternity Care Coal., Riverside MOMobile (2009) (on file with the National Women’s Law Center).
74 This measures those who are re-incarcerated within two years of release, either as a result of a new offense or violation of parole or probation. Since
the program is only three years old, this measure includes women who have no yet been released for two full years. E-mail from Marjie Mogul, Director
of Research, Maternity Care Coalition, to Micole Allekotte, Health Fellow, National Women’s Law Center (Sept. 30, 2009, 9:05 EST) (on file with
the National Women’s Law Center); E-Mail from Marjie Mogul, Director of Research, Maternity Care Coalition, to Micole Allekotte, Health Fellow,
National Women’s Law Center (Oct. 6, 2009, 11:08 EST) (on file with the National Women’s Law Center).
75 Maternity Care Coal., Riverside MOMobile (2009) (on file with the National Women’s Law Center); E-Mail from Marjie Mogul, Director of Research,
Maternity Care Coalition, to Micole Allekotte, Health Fellow, National Women’s Law Center (Oct. 6, 2009, 11:08 EST) (on file with the National
Women’s Law Center).
76 Id.
77 E-mail from Marjie Mogul, Director of Research, Maternity Care Coalition, to Micole Allekotte, Health Fellow, National Women’s Law Center
(Sept. 30, 2009, 9:05 EST) (on file with the National Women’s Law Center).
78 According to the Federal Health Resources and Services Administration, which has provided grants for doulas to serve communities, “a doula provides
culturally sensitive pregnancy, breastfeeding and childbirth education, and counseling. They also promote links to health care and social services, labor
coaching and parenting skills.” Press Release, Health Resources and Services Administration, HRSA Awards $6.3 Million to Launch New Parents
Initiative, “Doulas” Training (Oct. 3, 2008) (on file with author).
79 E-mail from Marjie Mogul, Director of Research, Maternity Care Coalition, to Micole Allekotte, Health Fellow, National Women’s Law Center
(Sept. 30, 2009, 9:05 EST) (on file with the National Women’s Law Center).
80 Maternity Care Coal., Riverside MOMobile (2009) (on file with the National Women’s Law Center); E-Mail from Marjie Mogul, Director of Research,
Maternity Care Coalition, to Micole Allekotte, Health Fellow, National Women’s Law Center (Oct. 6, 2009, 11:08 EST) (on file with the National
Women’s Law Center).
81 E-mail from Marjie Mogul, Director of Research, Maternity Care Coalition, to Micole Allekotte, Health Fellow, National Women’s Law Center
(Sept. 30, 2009, 9:05 EST) (on file with the National Women’s Law Center).
82 Fed. Bureau of Prisons, No. 5538.05, Program Statement, Escorted Trips (2008), available at http://www.bop.gov/policy/progstat/5538_005.pdf.
83 It should be noted that just because a state does not have a written policy explicitly restricting the use of restrains does not mean that it does not have
such policies regarding other related areas, such as training or transportation, as does Nevada.

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84 Barbara Bloom, Barbara Owen & Stephanie Covington, Gender Responsive Strategies: Research, Practice, and Guiding Principles for Women Offenders 11
(Nat’l Inst. of Corr. 2003).
85 Meaning whatever office has oversight of the entire prison.
86 These states are given two points: Pennsylvania never considers a woman who is being transported to give birth to be a security risk, and therefore no
assessment is made. In Utah, pregnant women’s levels of security risks are evaluated weekly at the Warden’s meeting, attended by the three deputies and
medical staff. California has a more comprehensive review process in which a committee made up of the warden and medical personnel assess a woman’s
security risk status either upon entry into the facility. In Nevada, once it is determined that a woman is pregnant, she is then housed in the infirmary
under the supervision of doctors and nurses.
87 Letter from Ralph Hale, Executive Vice President, American Coll. Of Obstetricians and Gynecologists, to Malika Saada Saar, Executive Director, The
Rebecca Project for Human Rights (June 12, 2007) (on file with author) (discussing the health risks faced by both mothers and unborn children when
pregnant women and shackled), available at http://www.acog.org/departments/underserved/20070612SaarLTR.pdf.
88 These states are given two points: Pennsylvania never considers a woman who is being transported to give birth to be a security risk, and therefore no
assessment is made of what type of restrains should be used. In Utah, pregnant women’s levels of security risks are evaluated weekly at the Warden’s
meeting, attended by the three deputies and medical staff, so medical staff input is considered. In Ohio, the only time physically immobilizing restraints
are used is at the request of the physician. In Nevada, once it is determined that a woman is pregnant, she is then housed in the infirmary under the
supervision of doctors and nurses.
89 Aisling Swift, Inmate Who Lost Baby in Collier Jail: I Want Them to Make Changes, Naples News, Feb. 14, 2009.
90 Id.; Aisling Swift, ACLU Probes Collier Jail’s Policies on Pregnant Inmates, Naples News, Mar. 1, 2009.
91 Aisling Swift, ACLU Probes Collier Jail’s Policies on Pregnant Inmates, Naples News, Mar. 1, 2009.
92 Aisling Swift, Inmate Who Lost Baby in Collier Jail: I Want Them to Make Changes, Naples News, Feb. 14, 2009.
93 See Nelson v. Corr. Medical Serv., 583 F.3d 522 (8th Cir. 2009).
94 Aisling Swift, Inmate Who Lost Baby in Collier Jail: I Want Them to Make Changes, Naples News, Feb. 14, 2009.
95 Anthony C. Thompson, Releasing Prisoners, Redeeming Communities Reentry, Race, and Politics 64-65 (NYU Press 2008).
96 Kathryn Icenhower, SHIELDS for Families, Inc.Tamar Village Semi-Annual Report (2008).
97 Jenni Vainik, Note, The Reproductive and Prenatal Rights of Incarcerated Mothers, 46 Fam. Ct. Rev. 670, 683 (2008).
98 Chandra Kring Villanueva et al., Mothers, Infants, and Imprisonment: A National Look at Prison Nurseries and Community-Based Alternatives 21 (Women’s Prison
Ass’n & Home 2009).
99 Gail T. Smith, Adoption and Safe Families Act of 1997 and Its Impact on Prisoner Mothers and Their Children, in Women and Girls in the Criminal Justice System:
Policy Issues and Practice Strategies 15-1, 15-6 (Russ Immargieon ed., Civic Research Inst. 2006).
100 Kelsey Kauffman, Prison Nurseries: New Beginnings and Second Chances, in Women and Girls in the Criminal Justice System: Policy Issues and Practice Strategies
20-1, 20-6 (Russ Immargieon ed., Civil Research Inst. 2006).
101 Barbara Bloom, Barbara Owen & Stephanie Covington, Gender Responsive Strategies: Research, Practice, and Guiding Principles for Women Offenders 5
(Nat’l Inst. of Corr. 2003).
102 Kelsey Kauffman, Prison Nurseries: New Beginnings and Second Chances, in Women and Girls in the Criminal Justice System: Policy Issues and Practice Strategies
20-1, 20-6 (Russ Immargieon ed., Civil Research Inst. 2006).
103 Chandra Kring Villanueva et al., Mothers, Infants, and Imprisonment: A National Look at Prison Nurseries and Community-Based Alternatives 10 (Women’s Prison
Ass’n & Home 2009).
104 Amy L. Lindemuth, Designing Therapeutic Environments for Inmates and Prison Staff in the United States: Precedents and Contemporary Applications, 8 J. of
Mediterranean Ecology 87, 91 (2007).
105 Chandra Kring Villanueva et al., Mothers, Infants, and Imprisonment: A National Look at Prison Nurseries and Community-Based Alternatives 10 (Women’s Prison
Ass’n & Home 2009).
106 PowerPoint: Mary W. Byrne, Responsive Parenting Support During the Prison Nursery and Reentry Years: Highlights from a Study in Progress: Maternal and Child
Outcomes of a Prison Nursery Program (Nov. 6, 2006), available at http://www.drugabuse.gov/whatsnew/meetings/children_at_risk/powerpoint/Byrne.ppt.
107 Anti Drug-Abuse Act of 1986, Pub. L. No. 99-570, 100 Stat. 3207 (1986).
108 Women Offenders and Their Children, Special Needs Offenders Bulletin (Federal Judicial Center, Washington, DC), Sept. 2001, at 6.
109 William J. Sabol & Heather C. West, NCJ 230113, Prison Inmates at Midyear 2009-Statistical Tables, Table 4 (Bureau of Justice Statistics 2010), available at
http://bjs.ojp.usdoj.gov/content/pub/pdf/pim09st.pdf.
110 Lauren E. Glaze & Laura M. Maruschak, NCJ 222984, Parents in Prison and Their Minor Children 2 (Bureau of Justice Statistics rev. 2009), available at
http://bjs.ojp.usdoj.gov/content/pub/pdf/pptmc.pdf.
111 See Bureau of Prisons, Institutions Housing Female Offenders, http://www.bop.gov/locations/female_facilities.jsp (last visited Sept. 16, 2009).
112 Homeland Security Act of 2002, Pub. L. No. 107-296, 82 Stat. 1226 (2002).
113 Human Rights Watch, Detained and Dismissed:Women’s Struggles to Obtain Health Care in United States Immigration Detention 2 (2009).
114 Dora Schriro, Immigration Detention Overview and Recommendations 27 (Immigration and Customs Enforcement 2009), available at http://www.ice.gov/
doclib/091005_ice_detention_report-final.pdf.

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115 Women’s Comm’n for Refugee Women and Children & Lutheran Immigration and Refugee Service, Locking Up Family Values:The Detention of Immigrant
Families 8 (2007), available at http://www.womensrefugeecommission.org/docs/famdeten.pdf.
116 See generally Dora Schriro, Immigration Detention Overview and Recommendations (Immigration and Customs Enforcement 2009), available at http://www.ice.
gov/doclib/091005_ice_detention_report-final.pdf.
117 28 C.F.R. § 551.22(a)-(c) (2010).
118 28 C.F.R. § 551.24(c) (2010).
119 Nat’l Ass’n of Women Judges, Priorities for Dealing with Incarcerated Women 3 (2009) (on file with The Rebecca Project for Human Rights).
120 Human Rights Watch, Detained and Dismissed:Women’s Struggles to Obtain Health Care in United States Immigration Detention 53 (2009).
121 Southwest Inst. for Research on Women, Univ. of Ariz. Coll. of Soc. and Behavioral Sci. & Bacon Immigration Law and Policy Program, Univ. of Ariz.
James E. Rogers Coll. of Law, Unseen Prisoners: A Report on Women in Immigration Detention Facilities in Arizona 22 (Univ. of Ariz. 2009).
122 Women’s Comm’n for Refugee Women and Children & Lutheran Immigration and Refugee Serv., Locking Up Family Values:The Detention of Immigrant
Families 1 (2007), available at http://www.womensrefugeecommission.org/docs/famdeten.pdf.
123 Human Rights Watch, Detained and Dismissed:Women’s Struggles to Obtain Health Care in United States Immigration Detention 52 (2009).
124 Rachel Roth, Searching for the State:Who Governs Prisoners’ Reproductive Rights?, 11 Soc. Pol. 411, 419 (2004).
125 This report was put forth by the American Bar Association, Criminal Justice Section, Report to the House of Delegates (Aug. 2007).
126 Fed. Bureau of Prisons, No. 5538.05, Program Statement, Escorted Trips (2008), available at http://www.bop.gov/policy/progstat/5538_005.pdf.
127 The Second Chance Act, Pub. L. No. 110-199, 122 Stat. 657 (2008) (requiring agencies to report on the use of restraints during “pregnancy, labor,
delivery of a child, or postdelivery recuperation” and “the reasons for the use of the physical restraints, the length of time that the physical restraints were
used, and the security concerns that justified the use of the physical restraints”).
128 The standard specifically states with regard to pregnant detainees:
Medical staff shall determine precautions required to protect the fetus, including safest method of restraint, presence of a medical professional and
medical necessity of restraining the detainee ICE/DRO Detention Standard, Use of Force and Restraints, § 5.F1, available at http://www.ice.gov/
doclib/PBNDS/pdf/use_of_force_and_restraints.pdf.
129 Kevin Sieff, Access Denied, Tex. Observer, Feb. 20, 2009 (citing Unseen Prisoners: A Report on Women in Immigration Detention Facilities in Arizona, supra note
121).
130 Southwest Inst. for Research on Women, Univ. of Ariz. Coll. of Soc. and Behavioral Sci. & Bacon Immigration Law and Policy Program, Univ. of Ariz.
James E. Rogers Coll. of Law, Unseen Prisoners: A Report on Women in Immigration Detention Facilities in Arizona 22 (Univ. of Ariz. 2009).
131 See generally Dora Schriro, Immigration Detention Overview and Recommendations (Immigration and Customs Enforcement 2009), available at http://www.ice.
gov/doclib/091005_ice_detention_report-final.pdf.
132 H.R. 1593, 110th Cong. §232 (2007).
133 42 U.S.C. §1997c (a)-(b) (requiring the Department of Justice to first seek to negotiate resolution of conditions that violate the constitutional rights of
prisoners).
134 Shackling during labor and delivery has been declared a violation of international human rights standards, including the United National Standard
Minimum Rules for the Treatment of Prisoners, the Convention Against Torture and the International Covenant on Civil and Political Rights. See
Amnesty International, Not Part of My Sentence:Violations of the Human Rights of Women in Custody 3-5 (1999).
135 See Nelson v. Corr. Medical Serv., 583 F.3d 522, 532-34 (8th Cir. 2009) (citing Women Prisoners of D.C. v. District of Columbia, 877 F.Supp. 634, 669 (D.D.C.
1994)).
136 U.S. Sentencing Comm’n, Guidelines Manual, §5C1.1(e) (2009).
137 U.S. Sentencing Comm’n, Alternative Sentencing in the Federal Criminal Justice System 11 (2009), available at http://www.ussc.gov/general/20090206_
Alternatives.pdf.
138 U.S. Sentencing Comm’n, Alternative Sentencing in the Federal Criminal Justice System 12 (2009), available at http://www.ussc.gov/general/20090206_
Alternatives.pdf.
139 Almost ninety-two percent of those convicted of drug offenses are sentenced to prison. Id. at 9.
140 U.S. Sentencing Comm’n, Guidelines Manual, §1B1.13 (2009) (referring to application notes).
141 U.S. Sentencing Comm’n, Guidelines Manual, §5H1.6 (2009).
142 Chandra Kring Villanueva et al., Mothers, Infants, and Imprisonment: A National Look at Prison Nurseries and Community-Based Alternatives 14 (Women’s Prison
Ass’n & Home 2009).
143 Id.
144 Id.
145 Joann B. Morton & Deborah M. Williams, Mother-Child Bonding: Incarcerated Women Struggle to Maintain Meaningful Relationships With Their Children, 60
Corrections Today [original pagination unavailable] (1998); Elizabeth Friar Williams, A Tie That Binds: Fostering the Mother-Child Bond in a Correctional
Setting, 58 Corrections Today [original pagination unavailable] (1996).
146 Tex. House Research Org., Requiring Residential Infant Care Programs for Mothers in Prison, Bill Analysis of HB 1992 (2007).

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147 Chandra Kring Villanueva et al., Mothers, Infants, and Imprisonment: A National Look at Prison Nurseries and Community-Based Alternatives 34 (Women’s Prison
Ass’n & Home 2009).
148 U.S. Immigration and Customs Enforcement, ICE Office of Detention and Removal, http://www.ice.gov/PI/NEWS/FACTSHEETS/DRO110206.
HTM.
149 Additionally, ICE detainees are denied the benefit of protection that those charged with criminal offenses have, such as a right to representation. Human
Rights Watch, Detained and Dismissed:Women’s Struggles to Obtain Health Care in United States Immigration Detention 2.
150 Dora Schriro, Immigration Detention Overview and Recommendations 20 (Immigration and Customs Enforcement 2009), available at http://www.ice.gov/
doclib/091005_ice_detention_report-final.pdf.
151 Women’s Comm’n for Refugee Women and Children & Lutheran Immigration and Refugee Serv., Locking Up Family Values:The Detention of
Immigrant Families 2-3 (2007) (citing UNHCR Report on Alternatives to Detention of Asylum Seekers and Refugees), available at http://www.
womensrefugeecommission.org/docs/famdeten.pdf.
152 Human Rights Watch, Detained and Dismissed:Women’s Struggles to Obtain Health Care in United States Immigration Detention 2 (2009).
153 Id. at 55.
154 Southwest Inst. for Research on Women, Univ. of Ariz. Coll. of Soc. and Behavioral Sci. & Bacon Immigration Law and Policy Program, Univ. of Ariz.
James E. Rogers Coll. of Law, Unseen Prisoners: A Report on Women in Immigration Detention Facilities in Arizona 21 (Univ. of Ariz. 2009).
155 But women who are detained for immigration violations are routinely separated from the U.S. citizen children. Id. at 44.
156 H.R. Rep. No. 109-79, at 38 (2005). For a comprehensive history of family detention policies, see Women’s Commission for Refugee Women and
Children, supra note 151.
157 Press Release, American Civil Liberties Union, ACLU Strikes Deal to Continue Humane Condition at Hutto Detention Center (Aug. 7, 2009) (on file
with author), available at http://www.aclu.org/immigrants-rights/aclu-strikes-deal-continue-humane-conditions-hutto-detention-center.
158 H.R. Rep. No. 111-157, at 55 (2010).
159 Id.
160 Indiana received the National Commission on Correctional Health Care’s Program of the Year award in 2003. Jaime Shimkus, Faculty Profile: One Size
Does Not Fit All at Indiana Women’s Prison, Nat’l Comm’n on Corr. Health Care, http://www.ncchc.org/pubs/CC/profiles/18-2.html.
161 Eighty percent of children of incarcerated mothers are placed with family members or friends, while twenty percent are in foster care. Less than one
percent are adopted by other families. Jane Schadee, Passport to Healthy Families, Indiana Women’s Prison, Corrections Today 1 (June 2003).
162 Maternal and Child Health Services Title V Block Grant, State Narrative for Indiana (2009), available at https://perfdata.hrsa.gov/MCHB/TVISReports/
Documents/2010/Narratives/IN-Narratives.pdf.
163 Jaime Shimkus, Faculty Profile: One Size Does Not Fit All at Indiana Women’s Prison, Nat’l Comm’n on Corr. Health Care, http://www.ncchc.org/pubs/
CC/profiles/18-2.html.
164 Patrick A. Langan & David J. Levin, Recidivism of Prisoners Released in 1994 tbl.8 (Bureau of Justice Statistics 2002), available at http://bjs.ojp.usdoj.gov/
content/pub/pdf/rpr94.pdf.
165 American Civil Liberties Union, State Standards for Pregnancy-Related Health Care in Prison (2008), available at http://www.aclu.org/reproductiverights/
gen/pregnancycareinprison.html. While ACLU’s data is used with the organization’s permission and ACLU staff has assisted in developing grades, the
ACLU’s report did not attempt to assign grades. We have also confirmed that the states receiving an F grade for not reporting data have not made data
publicly available since the publication of the ACLU report. The ACLU report also includes information on state’s policies regarding counseling inmates
on their pregnancy options. Since the scope of this report is limited to policies regarding inmates who choose to continue their pregnancies, we did nto
include the ACLU’s information regarding state policies on inmate’s legally protected right to terminate a pregnancy.
166 See Indicator Descriptions for more information on points awarded for each indicator.
167 See, e.g., David Badertscher, What’s Happening in Your State Related to Legislation Regarding the Use of Restraints on Pregnant Women, Criminal Law Library
Blog, Sept. 2, 2009, http://www.criminallawlibraryblog.com/2009/09/whats_happening_in_your_state_1.html.
168 Chandra Kring Villanueva et al., Mothers, Infants, and Imprisonment: A National Look at Prison Nurseries and Community-Based Alternatives (Women’s Prison
Ass’n & Home 2009).
169 We recognize that policies may be obtained through Freedom of Information Act (FOIA) requests. However, as states were also graded on the ease with
which policies could be accessed, we chose not to pursue FOIA requests.
170 Rachel Roth, Searching for the State:Who Governs Prisoners’ Reproductive Rights?, 11 Soc. Pol. 411, 418-19 (2004).
171 Girl Scouts Behind Bars and Girl Scouting in Detention Centers: Supporting Girls, Connecting Families, Brochure 4 (Girl Scouts USA, New York, N.Y.
2007).
172 Id. at 5.
173 Id. at 9.
174 Id. at 4.

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Mothers
Behind
Bars:
A state-by-state report
card and analysis of
federal policies on
conditions of
confinement for
pregnant and parenting
women and the effect
on their children