BREAKING PROMISES: VIOLATIONS OF THE MASSACHUSETTS PREGNANCY
STANDARDS & ANTI-SHACKLING LAW
© May 2016 The Prison Birth Project and Prisoners’ Legal Services of Massachusetts
Prison Birth Project
400 Dwight Street
Holyoke, MA 01040
collective@theprisonbirthproject.org
www.theprisonbirthproject.org
The Prison Birth Project is an organization focused on reproductive justice, working
to provide support, advocacy and resources to people at the intersection of the
criminal system and parenthood. Prison Birth Project provides continuous care
through the full spectrum of pregnancy, birth and the postpartum process. We offer
this in the form of childbirth education classes, one-on-one meeting time, open
resource compilation and organizing with those most affected by the issues.
We believe that through supporting women and children during times of transition
and change we can strengthen our families and our communities.
Prisoners’ Legal Services of Massachusetts
10 Winthrop Square, 3rd Floor
Boston, MA 02110
617-482-2773
lpetit@plsma.org
www.plsma.org
Prisoners’ Legal Services promotes the safe, humane and lawful treatment of
Massachusetts prisoners through civil rights litigation, administrative advocacy,
client counseling, and outreach to policy makers and the public.
This report was written by Rachel Roth, consultant, Lauren Petit, Staff Attorney,
Prisoners’ Legal Services of Massachusetts, and Marianne Bullock, Co-Director,
Prison Birth Project. We are grateful to the National Institute for Reproductive
Health for financial support and technical assistance, to our other donors,
supporters, and allies, and to the women who entrusted their stories to us.

CONTENTS

Introduction

1

Key Findings

2

Prisons and Jails in Massachusetts

3

Why Massachusetts Limited the Use of Restraints

4

Methodology for this Report

5

Findings: State Department of Correction and County Jail Policies on
Restraining Pregnant, Laboring, and Postpartum Women

6

State and County Compliance with the 2014 Anti-Shackling Law in
Official Written Policies (chart)

10

Findings: Department of Correction’s Mandate to Develop Statewide
Standards for Pregnant and Postpartum Women

12

Recommendations: Realizing the Promise of the 2014 Law

14

Text of the 2014 Pregnancy Standards and Anti-Shackling Law

17

Endnotes

19

In 2015, a woman in Massachusetts gave
birth by cesarean section. Exactly one week
later, she was taken to court in the back of a
van with no seatbelt; she was handcuffed,
restrained at her ankles, and had a chain
around her belly. She spent five hours in
significant pain and discomfort as she was
jostled around in the back of the van. To
make matters worse, the sterile bandages
holding the incision together from the
cesarean surgery split open during the trip.

“My concerns prior to delivery were that she was
going to be restrained during her way to the
hospital, during delivery or postpartum or she
would not make it to the hospital on time. My
fears came true. She was handcuffed on her way
to the hospital and arrived in a police vehicle at 2
AM. Approximately 9 minutes later she gave
birth to her son. She was also shackled to the
bed immediately after birth.
I am angered, appalled, and saddened that they
shackled her. What my daughter faced is cruel
and unusual punishment. It endangered my
daughter’s life, as well as her baby.”
– The mother of an incarcerated woman

s

“It was really hard. I couldn’t move like I
needed to—couldn’t hold my stomach or
push up to move myself around. The metal
would dig into me every time I did try to
grab my stomach during a contraction. It
was incredibly lonely going through that
experience by myself.”
– Her daughter, who was unlawfully
handcuffed while in labor on the way to the
hospital

INTRODUCTION

“All [people in prison] shall be treated with the respect due to their
inherent dignity and value as human beings.”1
In 2014, the Massachusetts legislature unanimously passed a groundbreaking bill
to promote the health of pregnant women in prison and jail. Signed by the governor
at a public ceremony, the law promotes women's health in two ways:



by limiting the use of restraints on pregnant and postpartum women, and
banning their use entirely during labor and childbirth, and
by requiring minimum standards of medical care, nutrition, and other
conditions of confinement during pregnancy and postpartum recovery.

The measure, often referred to as the “anti-shackling law,” took effect immediately.2
When Massachusetts enacted this law, it joined a growing number of states and
federal agencies that have restricted shackling, reflecting the consensus among
courts, medical societies, and human rights experts that restraining pregnant,
laboring, and postpartum women needlessly risks the health of women and their
fetuses.3
But the promise to respect the human rights of pregnant women in prison and jail
has been broken. Implementation of this law has fallen short.

Far too often Massachusetts prisons and jails violate the law in
both policy and practice, undermining the public will and
subjecting pregnant women to illegal, unsafe, and degrading
treatment.
This report is based on information from public records requests and
communications with corrections officials, medical providers, and women who
have been pregnant and incarcerated since the law took effect two years ago, and
is a joint effort of Prisoners’ Legal Services of Massachusetts and the Prison Birth
Project.4

BREAKING PROMISES: VIOLATIONS OF THE MASSACHUSETTS PREGNANCY STANDARDS & ANTI-SHACKLING LAW

1

KEY FINDINGS

 Neither the state Department of Correction nor a single County Sheriff’s Office fully
complies with the law.

 Knowledge of the law varies not just from one prison or jail to another, but among
corrections personnel who work for the same prison or jail.

 Women are being handcuffed in labor — in violation of the law.
 Women are being restrained to the hospital bed after they have their baby for no
reason — in violation of the law.

 Postpartum women are being restrained with ankle shackles and waist chains — in
violation of the law.

 Some pregnant women are taken to court or medical appointments in the back of
vans that have no seatbelts, where they slide around dangerously – and other
women are missing court dates altogether because of the failure to plan for a
proper vehicle; both these situations violate the law.

 The law requires “a diet containing the nutrients necessary to maintain a healthy
pregnancy,” but women either go hungry or make do without enough fruit,
vegetables, or fiber.

 The law requires “appropriate clothing” but women are given standard-issue
clothing that is too big or too small, rather than maternity clothes designed to fit
their bodies; among other issues, pants that are too long put women at risk of
tripping, falling, and hurting themselves or their fetuses.

 The law requires the development of statewide standards on health care, nutrition,
clothing, and other conditions of confinement for every prison and jail to follow; the
Department of Correction has yet to develop these standards.

2

BREAKING PROMISES: VIOLATIONS OF THE MASSACHUSETTS PREGNANCY STANDARDS & ANTI-SHACKLING LAW

PRISONS AND JAILS IN MASSACHUSETTS

In Massachusetts, the Department of Correction (DOC) operates the state prison
system, which includes two prisons for women. At the local level, county sheriffs’
offices operate jails for people waiting to go on trial or sentenced on misdemeanor
charges.
Massachusetts is somewhat unusual because only a few counties incarcerate
women in the local jail; other counties send women arrested in their jurisdiction to a
state prison or a regional jail to wait for trial or serve their sentence.5
Where Women in Massachusetts are Incarcerated
Institution

Incarcerated Groups

Massachusetts
Correctional
InstitutionFramingham (DOC)

Women sentenced to state prison (maximum and
medium security);

South Middlesex
Correctional Center
(DOC)

Women sentenced to state prison (minimum security
and pre-release)

Barnstable County
Correctional Facility

Women who are waiting to go on trial or serving a
sentence for a misdemeanor in Barnstable, Dukes and
Nantucket Counties

Bristol County
Sheriff’s Office
Women’s Center

Women who are waiting to go on trial or serving a
sentence for a misdemeanor in the county

Suffolk County South
Bay House of
Correction

Women who are waiting to go on trial or serving a
sentence for a misdemeanor in the county

Hampden County
Western
Massachusetts
Regional Women’s
Correctional Center

Women who are waiting to go on trial or serving a
sentence for a misdemeanor in Berkshire, Franklin,
Hampden, Hampshire, and Worcester Counties

Women who are waiting to go on trial or serving a
sentence for a misdemeanor in Essex, Middlesex,
Norfolk and Plymouth Counties

As the table shows, four counties operate jails that incarcerate women: Barnstable,
Bristol, Hampden, and Suffolk; the Hampden County jail is a large regional jail.
Whether or not counties incarcerate women in their jails, every county sheriff is, at
minimum, responsible for driving women who were arrested in their county to court
and medical appointments. Because of this responsibility, they are all required to
have a written policy that spells out how employees should comply with the 2014
law’s restrictions on the use of restraints.

BREAKING PROMISES: VIOLATIONS OF THE MASSACHUSETTS PREGNANCY STANDARDS & ANTI-SHACKLING LAW

3

WHY MASSACHUSETTS LIMITED THE USE OF
RESTRAINTS
“Health is a fundamental human right, especially for individuals
held in the custody of the state.”6
Numerous medical authorities, including the American Congress of Obstetricians
and Gynecologists and the American Medical Association, agree that restraining
women during pregnancy and after childbirth is dangerous. Restraints impair
women’s balance and limit their mobility, increasing the risk of tripping and falling
and the risk of dangerous blood clots. Falling can result in injury to the pregnant
woman, as well as harm to her fetus, including the separation of the placenta from
the uterus (placental abruption), hemorrhage, and stillbirth. Restraints also interfere
with health care providers’ ability to intervene in medical emergencies. The
Massachusetts statute mandated comprehensive protection for pregnant and
postpartum women in jail and prison in recognition of the full continuum of risks.7
However, women are not fully benefiting from these protections because of
insufficient compliance. Successful implementation of the 2014 law requires both
significant changes in official written policies and full compliance with those written
policies in practice. And yet, there have been violations in practice even in
jurisdictions in which a written policy complies with the law. Moreover, conduct
among a jail or prison’s staff sometimes varies, with one shift following the law and
the next shift violating the law. These violations show the need for training and
education of all prison and jail employees who supervise women, with extra
emphasis on the responsibilities of employees who supervise women in
courthouses, hospitals, or other places outside of jail or prison, as well as
administrative leadership at all levels to establish expectations that all staff will act
in accordance with the law.

4

BREAKING PROMISES: VIOLATIONS OF THE MASSACHUSETTS PREGNANCY STANDARDS & ANTI-SHACKLING LAW

METHODOLOGY FOR THIS REPORT

The chart on page 10 and the analysis contained in this report are based on
information obtained from public records requests about compliance with the antishackling provisions of the 2014 law by Prisoners’ Legal Services. The DOC and
counties provided excerpts of policies or copies of policies on the use of restraints,
transportation, and/or in-hospital security.8 Prisoners’ Legal Services analyzed
these policies and provided written feedback to each prison or jail about problem
areas.
Prisoners’ Legal Services also obtained additional documents from the DOC and the
four counties that have jail facilities for women about the health-related provisions
of the 2014 law. Some of these additional documents contain language about
restraining pregnant women that violates the statute. In fact, the DOC and all four of
these counties have written policies that violate aspects of the statute and, in some
cases, contradict other written policies. For example, written procedures at the
state prison in Framingham in effect as late as March 2016 state that pregnant
women admitted to an outside hospital “shall be secured to the bed by one
handcuff or leg iron,” state that only women in “active” labor should not be
restrained, and allow the use of waist chains on pregnant women.9 Similarly, Bristol
County provided written material that clearly conflicts with the statute, specifying
that women shall be handcuffed during delivery and shall be “placed in leg irons
and/or handcuffs” after giving birth unless medically contraindicated, in which case
“only handcuffs shall be applied.”10 The information from these health-related
policies is not included in the findings presented below; however, corrections staff
are likely to be misdirected by these contradictory policies, undermining their ability
to do their job.

BREAKING PROMISES: VIOLATIONS OF THE MASSACHUSETTS PREGNANCY STANDARDS & ANTI-SHACKLING LAW

5

FINDINGS: STATE DEPARTMENT OF CORRECTION
AND COUNTY JAIL POLICIES ON RESTRAINING
PREGNANT, LABORING, AND POSTPARTUM
WOMEN
The Massachusetts anti-shackling bill became law on May 15, 2014, after being
passed unanimously by the legislature and signed by the governor. Once this bill
became law, the DOC and county sheriffs’ offices were responsible for taking the
specific requirements in the statute and turning them into everyday routines in
official policies or procedures for employees to follow.

Neither the Department of Correction nor a single county has
official written policies that comply fully with the law.
Jurisdictions’ shortcomings range from failure to comply with one provision of the
law to failure to comply with seven of eight key provisions. In certain cases, county
policies ignore some requirements of the law altogether; this omission results in
corrections officers defaulting to a general policy that violates the law on how to
treat pregnant women.
The findings below outline lack of compliance with eight specific provisions of the
law in official written policies. They also identify violations of the law in practice.

Ban on Restraints during Labor
The DOC and 10 counties
have policies that comply
with the ban on restraining
women during labor and
childbirth.

“When the nurse left, the officer stood up and
said that since I was not confirmed to be in
‘active labor,’ she would need to restrain me
and that she was sorry, but those were the
rules…
It was really my worst nightmare, being told
there was a law to prohibit this, but now here I
was, experiencing it.”

Some corrections staff
have restrained women in
labor, including several
who insisted on
handcuffing women until
they were deemed to be in “active labor” — a clear violation of the law, as well as the
jail’s own policies, both of which prohibit restraints during “any stage of labor.”

Four counties (Barnstable, Berkshire, Nantucket, and Suffolk) have
policies that violate the ban on restraints during labor; two of these
counties incarcerate women in their jails (Barnstable and Suffolk).

6

BREAKING PROMISES: VIOLATIONS OF THE MASSACHUSETTS PREGNANCY STANDARDS & ANTI-SHACKLING LAW

FINDINGS (cont’d)

Ban on Postpartum Restraints in the Hospital except in
“Extraordinary Circumstances” as Defined by the Law and
Accurate Definition of “Extraordinary Circumstances”
In written policy, the DOC and all
counties except for Bristol County
comply with the ban on restraining
women after they give birth and
during their time in the hospital.
The law and these policies require
that women not be restrained
unless there are “extraordinary
circumstances” in which an
individual “presents an immediate
and serious threat to herself or others” or “an immediate and credible risk of escape
that cannot be curtailed by other reasonable means.” Even under such
circumstances, only handcuffs may be used. The DOC and nine counties have
policies that accurately define “extraordinary circumstances” that justify the use of
restraints in accordance with the law.
“I took a shower after the birth and they
put me back in bed and shackled me to
the bed by my left ankle. I said it was
against the law, but the female C.O. said
she had never heard of that. She called
the jail and whoever she talked to also
said they never heard of it. So I stayed
shackled to the bed.”

In some cases, corrections staff have restrained women to the bed after they have
given birth, in violation of the law and even in violation of their own agency’s policy,
while in other cases women successfully advocated for their rights and prevented a
corrections officer from restraining them when they were in the hospital. Although
some women have been able to prevent their rights from being violated, no woman
should be forced to engage in arguments with corrections staff to obtain her rights
under the law.
Five counties have policies that violate the law by inaccurately defining
“extraordinary circumstances” (Berkshire, Bristol, Middlesex, Norfolk, and
Suffolk).

Ban on Postpartum Restraints during Transportation,
Except in “Extraordinary Circumstances” as Defined by
the Law
The DOC and 11 counties have policies that violate the ban on restraining women
during the drive back to prison or jail after giving birth. The three counties that have
policies that comply are Franklin, Hampden, and Norfolk. The statute states that in
a woman’s second and third trimester as well as during post-delivery recuperation
as determined by the attending physician, women “may only be restrained using
handcuffs in front,” and that a woman “in post-delivery recuperation shall not be

BREAKING PROMISES: VIOLATIONS OF THE MASSACHUSETTS PREGNANCY STANDARDS & ANTI-SHACKLING LAW

7

FINDINGS (cont’d)

placed in restraints, except under extraordinary circumstances.” Eight of the 11
policies that violate this provision of the law do so by mandating the use of
handcuffs and also by misapplying the “extraordinary circumstances” exception to
permit the use of additional restraints, contrary to the law.11
The DOC and 11 counties have policies that violate the ban on
restraining women during the drive back to prison or jail after giving
birth.

Ban on Leg and Waist Restraints throughout Pregnancy
and Postpartum
In a related problem, 11 counties have policies that violate the statute’s unequivocal
statement that, “Leg or waist restraints shall not be used on a pregnant or
postpartum [woman].” Only the DOC and Essex, Hampshire, and Plymouth Counties
have policies that correctly restate this prohibition in the law. Notably, however,
these four jurisdictions specifically define or treat the postpartum recovery period
as only the time before a woman is released from the hospital, rather than the
commonly accepted medical definition of “postpartum” as the six weeks following
birth or longer as determined by a woman’s physician.12
The DOC alone has policy language that specifically defines the ban on leg irons
and waist chains for a postpartum period to be determined by the treating
physician. Given the internal conflicts in county policies, it is likely that only the DOC
policy complies with the law’s provisions in this area. These policies increase the
likelihood that women will be shackled at the ankles and chained at the waist
despite the prohibition in the law.
In fact, women have been restrained with leg irons and waist chains on the way
back from the hospital. When one woman questioned the corrections officer who
shackled her at the ankles, he replied, “You’re not pregnant anymore” — completely
ignoring the ban on leg restraints on postpartum women. Other women, including
women who have delivered their babies by cesarean section, have reported being
restrained in waist chains and leg irons on trips to court and medical appointments
shortly after giving birth.
Eleven counties have policies that violate the statute’s unequivocal
statement that, “Leg or waist restraints shall not be used on a
pregnant or postpartum [woman].”

8

BREAKING PROMISES: VIOLATIONS OF THE MASSACHUSETTS PREGNANCY STANDARDS & ANTI-SHACKLING LAW

FINDINGS (cont’d)

Allow Doctor or Nurse to Order the Removal of Restraints
The DOC and 11 counties have policies that follow the law in allowing medical
providers to order the removal of restraints from a patient in their care. The other
three simply ignore this requirement.
Three counties have policies that violate the authority of medical
providers to order the removal of restraints (Berkshire, Bristol, and
Suffolk).

Officer in Room Should Be Female and Respect Privacy
The DOC and 10 counties have policies that comply with the provision of the law
stating that if a corrections staff person is in the hospital room during physical
exams, labor, or childbirth, that staff person should be female and should be
positioned in a way to respect the birthing woman’s privacy, if possible.
Four counties have policies that violate either the law’s preference
for female officers or respect for the woman’s privacy (Berkshire,
Bristol, Norfolk, and Suffolk).

Require Seatbelts in Second and Third Trimesters and
Postpartum
The DOC and four counties have policies that fail
“I should have had a
to require seatbelts or scale back the requirement
hearing two weeks ago,
to use vehicles with seatbelts when driving
but when I got down for
women in the second and third trimesters of
transport, they never sent
pregnancy and postpartum. In some cases,
a van with a seatbelt. A
corrections’ employees still drive pregnant
white shirt was there and
women to court or medical appointments in vans
told us ‘pregnant girls
without seatbelts, putting women at risk of injury
can’t go today.’”
from bouncing and sliding across the open
benches while restrained by handcuffs. In other
cases, corrections staff cause women to miss their court dates or medical
appointments by failing to plan for an appropriate vehicle. This failure can result in
needlessly extending a woman’s imprisonment when the judge might have released
her from custody at the hearing.
The DOC and four counties have policies that fail to require seatbelts
or scale back the requirement to use vehicles with seatbelts when
driving women in the second and third trimesters of pregnancy and
postpartum (Berkshire, Bristol, Essex, and Suffolk).
BREAKING PROMISES: VIOLATIONS OF THE MASSACHUSETTS PREGNANCY STANDARDS & ANTI-SHACKLING LAW

9

State and County Compliance with the 2014 Anti-Shackling Law in Official Written Policies

MA Dept. of
Correction
Barnstable
Berkshire
Bristol
Dukes
Essex
Franklin
Hampden
Hampshire
Middlesex
Nantucket12
Norfolk
Plymouth
Suffolk
Worcester

Bans restraints
during labor

Bans postpartum
restraints in
hospital*

Bans postpartum
restraints in
transportation*

Bans leg and
waist restraints

Accurately
defines
“extraordinary
circumstances”

MD or nurse can
order removal
of restraints

Officer in room
should be
female and
respect privacy

Requires
seatbelts

✔

✔

X1

✔

✔

✔

✔

X

X 2,11
X4
✔
✔
✔
✔
✔
✔
✔
X 2, 11
✔
✔
X4
✔

✔
✔
X8
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔

X3
X3
X8
X3
X3
✔
✔
X3
X1
X3
✔
X 13
X3
X3

X
X
X
X
✔
X 11
X
✔
X
X
X 11
✔
X
X 11

✔
X5
X 5,6,7
✔
✔
✔
✔
✔
X5
✔
X5
✔
X5
✔

✔
X8
X8
✔
✔
✔
✔
✔
✔
✔
✔
✔
X8
✔

✔
X9
X8
✔
✔
✔
✔
✔
✔
✔
X 9,11
✔
X9
✔

✔
X8
X 10
✔
X8
✔
✔
✔
✔
✔
✔
✔
X8
✔

* Except in extraordinary circumstances

KEY
✔ Complies

X Violates

Explanations
1. DOC and Middlesex County policy define post-delivery recuperation as the period of hospitalization and allow handcuffing postpartum women on the trip back from the hospital. DOC policy
creates a second category called “postpartum recuperation,” defined as “determined by a licensed health care professional” during which leg and waist restraints cannot be used.
2. Barnstable County policy only prohibits restraint in “active labor,” contrary to the law, in one of its three relevant policies.
3. The policy requires handcuffing postpartum women in transportation and also allows for additional restraint in “extraordinary circumstances,” contrary to the law.
4. The policy prohibits restraint of women in labor in a hospital but not during transportation to the hospital, contrary to the law.
5. The policy does not comply with the law’s requirements for documentation of the reason for restraining a woman under “extraordinary circumstances.”
6. The policy does not require the approval of the Superintendent to restrain a woman under “extraordinary circumstances,” contrary to the law.
7. The policy does not define “extraordinary circumstances” warranting postpartum restraint consistent with the law.
8. The policy does not address this provision at all. Failure to address this provision in the policy results in officers defaulting to a general policy that violates the law on restraint of pregnant
women.
9. The policy does not specify that any officer in the hospital room should be female.
10. Bristol County policy limits seatbelts to scheduled, non-emergency medical trips, leaving out all court trips and any unscheduled trips.
11. The policy contains contradictory provisions on this point, some in compliance with and some in violation of the law.
12. Nantucket County has no policy and states that it will follow Barnstable County’s policy.
13. Plymouth County policy defines “post-delivery recuperation” as the period of hospitalization and does not address restraints on the trip back from the hospital.
10

BREAKING PROMISES: VIOLATIONS OF THE MASSACHUSETTS PREGNANCY STANDARDS & ANTI-SHACKLING LAW

BREAKING PROMISES: VIOLATIONS OF THE MASSACHUSETTS PREGNANCY STANDARDS & ANTI-SHACKLING LAW

11

FINDINGS: DEPARTMENT OF CORRECTION’S
MANDATE TO DEVELOP STATEWIDE STANDARDS
FOR PREGNANT AND POSTPARTUM WOMEN
The law requires the Department of Correction to consult with the Department of
Public Health and the Massachusetts Sheriffs’ Association to develop minimum
standards of pregnancy-related care for every prison and jail to follow. The purpose
of this requirement is to replace the current patchwork of local policies with one
uniform standard ensuring that women will receive appropriate prenatal and
postpartum care and nutrition wherever they are incarcerated. More than one year
after the law took effect, the DOC had not begun the process of developing these
statewide standards, and the DOC has never indicated any progress on this
responsibility under the law.

Requires Prisons and Jails to Provide Pregnancy-Related
Medical Care
The quality and consistency of prenatal care is an area of considerable concern.
Although the statute requires at least one staff person to be trained in pregnancyrelated care, including nutrition, drug use, and other topics, it is not clear that every
jurisdiction is meeting this requirement. Two counties did not address this matter
at all in their response to the public records request. The DOC provided a list of all
staff positions but did not identify the particular staff member(s) with this training.
One county indicated that all but one member of the licensed medical staff have
had this training, including seven Licensed Practical Nurses; however, this
expertise goes beyond the scope of practice of Licensed Practical Nurses. As the
story below shows, at least some women do not appear to be receiving appropriate
medical care.
Despite coming into jail with a diagnosed high-risk pregnancy,
one woman did not see an obstetrician for approximately two
months. She nearly gave birth to her son in a jail cell because jail
medical staff dismissed her symptoms of labor and repeated
requests for help. The evening she went into labor, one of the
nurses on duty expressed concern over her blood pressure, but
the other nurses insisted she could wait to go to the hospital the
next day. After giving birth, this woman had a postpartum seizure
requiring hospitalization; this may have been prevented with
better medical care. High blood pressure and its consequences
are among the most common pregnancy complications, for
which any prison or jail should be prepared.

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BREAKING PROMISES: VIOLATIONS OF THE MASSACHUSETTS PREGNANCY STANDARDS & ANTI-SHACKLING LAW

FINDINGS (cont’d)

Requires Prisons and Jails to Meet Pregnancy-Specific
Needs
In addition to medical care, the law
addresses other issues of daily
importance, and requires prisons and jails
to meet the pregnancy-specific nutritional
and clothing needs of any pregnant
woman in their custody. However, women
consistently say they either do not get
enough food and feel hungry or they get
too many empty calories and not enough
fruit, vegetables, and fiber.

“It’s like that show ‘Punk’d’ on
TV, they put up signs in the
kitchen about how many
fresh fruits and vegetables
we should eat every day…
then serve us food that
doesn’t have any of that!”

Women also report being given extra large sizes of standard-issue clothing no
matter how tall they are or what size clothing they wear. Such clothing is not
appropriate because it does not accommodate an individual’s changing body.
Pants that are too long put pregnant women at risk of tripping, falling, and injuring
themselves and injuring their fetus. In addition, women can be disciplined for
wearing pants that slip down and are not allowed to use a belt to keep them up,
putting them in a no-win situation.
“The worst part of my entire experience was being hungry. I was
so hungry the entire time I was locked up. The [supplemental]
pregnancy meal that is provided is a piece of cheese on two
pieces of white bread and a carton of milk. Even if I could
stomach that every day, it didn’t cut it. I needed fruit. Vegetables.”

BREAKING PROMISES: VIOLATIONS OF THE MASSACHUSETTS PREGNANCY STANDARDS & ANTI-SHACKLING LAW

13

RECOMMENDATIONS: REALIZING THE PROMISE
OF THE 2014 LAW
Restraining people who are being taken outside of prison or jail has long been the
norm; however, Massachusetts policymakers have now universally recognized that
restraining pregnant and postpartum women is medically risky, unnecessary, and
inhumane. While implementing new policies in large institutions is often
challenging, the Massachusetts legislature enacted this law precisely in order to
bring about a change in the way that women are treated when they are pregnant
and recovering from childbirth, and corrections officials are required to comply.
Indeed, in response to inquiries from Prisoners’ Legal Services, the DOC and some
counties made changes to their policies.13 In an example of successful advocacy
and collaboration, the superintendent in one county where a woman had been
unlawfully restrained subsequently implemented new procedures and additional
training for officers in order to achieve better compliance with the law. Other
counties declined to take such steps.
As this report shows, in order to fully comply with the 2014 law, the DOC and each
county must undertake a thorough review of all of their policies and procedures,
including those relating to the movement and treatment of women inside of prison
or jail, and ensure that all policies and procedures reflect the statutory limits on the
use of restraints.

Massachusetts is a national leader in providing health care to
all residents. But health reform in the state and at the federal
level hasn’t resulted in better medical care in prison. This law
begins to correct for that omission where pregnant and
postpartum women are concerned — but only if every prison
and jail follows it.
The recommendations on the following pages would enhance the law’s focus on
safeguarding women’s health and also improve compliance with the law. These
recommendations can be achieved through regulation and oversight by the
relevant government agencies, actions of prison and jail administrators, or
additional legislation.
Massachusetts took an important step by passing the landmark 2014 law. It is
time to make good on the promise of that law and ensure that the state fulfills its
responsibility to give every woman in prison and jail the best possible chance for a
healthy pregnancy and birth.

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RECOMMENDATIONS

The recommendations listed here would enhance the law’s focus on safeguarding
women’s health and improve compliance with the law. These recommendations
can be achieved through regulation and oversight by the relevant government
agencies, actions of prison and jail administrators, or additional legislation.



The statutory ban on restraints during any stage of labor or childbirth must be
fully enforced.



The statutory ban on leg and waist restraints throughout pregnancy must be
fully enforced.



Postpartum recovery should be explicitly defined as six weeks, or longer if
considered necessary by a health care professional in the hospital where a
woman delivers her baby, and the statutory limits on handcuffs and ban on leg
and waist restraints must be fully enforced throughout this period. This sixweek time frame is the standard in the community. Women who give birth while
incarcerated experience the same physiological changes as other women and
have the same needs for time to recover from giving birth. Indeed, healing is
more challenging in prison and jail without even basic comforts, the ability to
rest when needed, or the caring attention of friends and family.



The law mandates the development of statewide standards for pregnancy and
postpartum recovery, including health care, nutrition, and other conditions of
confinement. These standards should reflect best practices in the community.
Adherence to the standards should be monitored in every prison and jail in
which women are incarcerated.



Emergency medical personnel should have the authority to determine that a
woman is in labor, so that emergency personnel who respond to calls from
prisons or jails can protect patients in their care from being restrained when
they are in labor and need to go to the hospital.



All prison and jail staff who supervise women or drive women to court or
medical facilities should be trained on the law governing the use of restraints
on an ongoing basis. Corrections personnel cannot be expected to comply with
the law if they have not been trained on what the law requires and how to do
their jobs in a manner that upholds the law.

BREAKING PROMISES: VIOLATIONS OF THE MASSACHUSETTS PREGNANCY STANDARDS & ANTI-SHACKLING LAW

15

RECOMMENDATIONS

16



All instances in which corrections staff restrain pregnant or postpartum women
must be documented in writing. The law currently requires documentation of
the type of restraints used and the reasons why they were deemed necessary
when a corrections officer restrains a woman under the exception allowed by
the law. These reports, which are now internal documents, should be promptly
submitted to the Secretary of Public Safety for review. The Secretary of Public
Safety should issue an annual report compiling information about these
incidents (without naming the individuals involved). This regular accounting will
allow policymakers and the public to see how the law is working and what
problem areas may need to be addressed.



Data collection systems to keep track of the numbers of pregnant women in
prison and jail and the outcomes of their pregnancies should be developed and
implemented, and the information should be made accessible to the public.



Every woman who is incarcerated while pregnant or in postpartum recovery
must be informed of her rights under the law.



Alternatives to incarceration should be developed and implemented. Pregnant
women are safer when they can freely seek medical attention for signs of
complications or labor and when they can give birth free of restraints and with
the support of family and friends. While the stakes for pregnant women are
especially high because of the risks that prison and jail conditions pose to their
health and the health of their fetuses, many individuals, families, and
communities would benefit from alternatives to incarceration, for example,
people too poor to pay bail while waiting to go on trial and people who come
into contact with the criminal justice system because of an underlying mental
health challenge, including drug or alcohol use. Taxpayers would also benefit
from policies that reserve the use of incarceration for people who pose a
serious threat to the community and reinvest public resources from
incarceration to health care and social services that give people a chance to
lead healthy lives.14

BREAKING PROMISES: VIOLATIONS OF THE MASSACHUSETTS PREGNANCY STANDARDS & ANTI-SHACKLING LAW

TEXT OF THE 2014 PREGNANCY STANDARDS
AND ANTI-SHACKLING LAW
Massachusetts General Laws chapter 127 § 118
Pregnant and postpartum inmates; standards of care; use of restraints
Effective: May 15, 2014
(a) Upon admission to a correctional facility, while awaiting trial or after
sentencing, a female inmate shall be screened and assessed for pregnancy by a
licensed health care professional; provided, however, that the inmate shall be
informed of any necessary medical tests connected with the pregnancy screening
prior to the administration of such tests. A pregnant inmate shall receive
nondirective counseling and written material, in a form the inmate can understand,
on pregnancy options and correctional facility policies and practices regarding
care and labor for pregnant inmates. Correctional facilities housing female inmates
shall ensure that at least 1 member of the correctional facility’s medical staff is
trained in pregnancy-related care, which shall include knowledge of prenatal
nutrition, high-risk pregnancy, addiction and substance abuse during pregnancy
and childbirth education.
A pregnant and postpartum inmate shall be provided regular prenatal and
postpartum medical care at the correctional facility in which she is housed,
including: periodic health monitoring and evaluation during pregnancy; the
opportunity for a minimum of 1 hour of ambulatory movement each day; a diet
containing the nutrients necessary to maintain a healthy pregnancy, including
prenatal vitamins and supplements; postpartum screening for depression; and
written information regarding prenatal nutrition, maintaining a healthy pregnancy
and childbirth. Pregnant and postpartum inmates shall be provided appropriate
clothing, undergarments and sanitary materials.
The department of correction shall, in consultation with the department of public
health and the Massachusetts Sheriffs Association, Inc., develop appropriate
standards of care for pregnant and postpartum inmates, which shall include, at a
minimum, the standards for health services set forth by the National Commission
on Correctional Health Care. If a pregnant inmate requires medically necessary,
specialized care that is unavailable at the correctional facility, the pregnant inmate
shall have access to such care at a supporting medical facility with appropriate
expertise.
If a licensed health care professional determines that an inmate is suffering from
postpartum depression, she shall have regular access to a mental health clinician.
A postpartum inmate shall not be subject to isolation absent an individualized,
documented determination that the inmate poses a serious risk of harm to herself
or others.
Prior to release, correctional facility medical staff shall provide a pregnant inmate
with counseling and discharge planning in order to ensure continuity of pregnancyrelated care, including uninterrupted substance abuse treatment.

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17

TEXT OF THE 2014 LAW (cont’d)

(b) During the second and third trimesters of pregnancy or during post-delivery
recuperation, as determined by the attending physician, an inmate shall be
transported to and from visits to medical providers and court proceedings in a
vehicle with seatbelts and may only be restrained using handcuffs in front.
A pregnant inmate shall receive labor and delivery care in an accredited hospital
and shall not be removed to another penal institution for the purpose of giving
birth. An inmate who is in any stage of labor or delivery, as determined by a
licensed health care professional, shall not be placed in restraints at any time,
including during transportation. If a correction officer is present in the room during
the pregnant inmate’s physical examinations, labor or childbirth, the officer shall, if
possible, be female. Whenever possible, the correction officer shall be positioned
in a location in the room that will ensure, to the extent possible, patient privacy.
During post-delivery recuperation, an inmate shall remain in the hospital until the
attending physician certifies that she may be safely discharged and transferred
back to the correctional facility. An inmate in post-delivery recuperation shall not
be placed in restraints, except under extraordinary circumstances.
For the purposes of this section, “extraordinary circumstances” shall mean a
situation in which a correction officer determines that the specific inmate presents
an immediate and serious threat to herself or others or in which the inmate
presents an immediate and credible risk of escape that cannot be curtailed by
other reasonable means. If an inmate is restrained, the restraints shall be the least
restrictive available and the most reasonable under the circumstances. Leg or
waist restraints shall not be used on a pregnant or postpartum inmate. In the event
the correction officer determines that extraordinary circumstances exist and
restraints are used, the correction officer shall fully document, in writing, the
reasons that the officer determined such extraordinary circumstances existed, the
kind of restraints used and the reasons those restraints were considered the least
restrictive available and the most reasonable under the circumstances. A
superintendent shall approve the use of any restraints used due to extraordinary
circumstances either before the officer makes the determination or after the
correction officer submits documentation detailing the reasons restraints were
required. If the attending physician or nurse treating the pregnant inmate requests
that restraints be removed for medical reasons, the correction officer shall
immediately remove all restraints.
(c) Nothing in this section shall prohibit the use of hospital restraints requested by
a treating physician for the medical safety of a patient.

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ENDNOTES

1

Basic Principles for the Treatment of Prisoners, adopted and proclaimed by the United Nations
General Assembly resolution 45/111 (14 December 1990), available online.
2
Massachusetts General Laws chapter 127, § 118, effective immediately, May 15, 2014. See
page 17-18 of this report for the full text of the statute. (Once a bill is passed and codified, it
can be referred to as a law or as a statute.)
3
Massachusetts was the 21st state to adopt a statute limiting the use of restraints on pregnant
women. For more information on the issue nationally, see University of Chicago Law School
International Human Rights Clinic, et al., CAT Shadow Report: The Shackling of Incarcerated
Pregnant Women (Submitted to the United Nations in 2014), available online.
4
The law’s protections should apply to any person who is pregnant and incarcerated, including
transgender people. Because all of the information we have about people’s experiences is
from individuals who identify as women, we use the term “pregnant woman” to refer to any
person who is pregnant and incarcerated in this report. While we believe that the state
Department of Correction and county jails typically assign individuals to prison and jail based
on their genitalia rather than each individual’s preference, we do not have definitive information
on policies and practices for every jurisdiction in the state. We are also aware that some
transgender and gender-nonconforming people hide their identity while they are incarcerated,
in order to protect themselves from harassment and abuse. Transgender and gendernonconforming people face significant barriers to health care in prison and jail in addition to
the barriers that all incarcerated people routinely confront. We support all individuals’ access
to the health care they need.
5
We use the term “jail” as shorthand for county jails and county Houses of Correction
throughout the report. The DOC and/or Sheriffs may make other arrangements for the
incarceration of women, depending on whether any given jail or prison is at or over capacity. In
addition, some counties may have a few cells reserved for women who are, for example,
arrested over the weekend and will not see a judge until Monday. By and large, the table
reflects the current arrangement for the incarceration of women throughout the state.
6
Kyiv Declaration on Women’s Health in Prison, p. v, adopted by the World Health Organization
Regional Office for Europe in 2008, available online.
7
American College of Obstetricians and Gynecologists, Health Care for Pregnant and
Postpartum Incarcerated Women and Adolescent Females, Committee Opinion No. 511 (2011),
pp. 2-3, available online; C. Sufrin, A. Kolbi-Molinas, and R. Roth. “Reproductive Justice, Health
Disparities and Incarcerated Women in the United States,” Perspectives on Sexual and
Reproductive Health vol. 47, no. 4 (2015), p. 216.
8
Nantucket County has not created a policy in response to the law. Their stated intent is to
follow the Barnstable County policy on transportation of pregnant women.
9
MCI-Framingham 620(II)(10) and (11), “Special Health Care Practices/Programs for Pregnant
Inmates,” dated November 2014 and provided as current policy in March 2016. In response to
advocacy from Prisoners’ Legal Services, the DOC revised the policy to comply with the law;
the new policy is dated April 2016.
10
Bristol County Sheriff’s Office procedures on “Management of Pregnant Inmates,” section
12.12.09, and “Hospital Room Security Procedures,” (p. 10), dated 08/22/11. This document
pre-dates the 2014 law. Because the sheriff’s counsel supplied this document on July 28,
2015 in response to a request for records relating to the treatment of pregnant women, it
appears that the sheriff’s office considers it an active policy.
11
These interpretations appear to rest on the statute’s use of the phrase “post-delivery
recuperation,” which the policies generally equate with the time a woman is in the
hospital. Such an interpretation requires assuming that during their hospitalization
immediately after giving birth, women are being brought to court and to appointments with
BREAKING PROMISES: VIOLATIONS OF THE MASSACHUSETTS PREGNANCY STANDARDS & ANTI-SHACKLING LAW

19

ENDNOTES

medical providers that require transportation in a vehicle — contrary to common sense and
practice. Instead, the plain wording of the law requires that women NOT be restrained during
the drive back to the jail or prison after childbirth or during the remainder of their postpartum
recovery unless extraordinary circumstances require it. In that circumstance, the only
permissible restraints would be handcuffs in front. Essentially, these non-compliant policies
limit an incarcerated woman’s postpartum recovery to only a day or two, after which time, on
the way back to prison or jail, she is automatically handcuffed and, by most policies, can be
subjected to additional restraints. The medical understanding of postpartum recovery is six
weeks for an uncomplicated delivery, and the aim of the law is clearly to protect women’s
health and safety throughout this period.
An additional problem exists in the state’s regulations on the use of restraints. In February
2014, then-Governor Deval Patrick issued emergency regulations to curtail county sheriffs’
use of restraints on pregnant women. The DOC, which is responsible for writing regulations
that apply to the counties, later issued permanent regulations that fall short of the statute,
despite the comments submitted by Prisoners’ Legal Services, the ACLU, NARAL Pro-Choice
Massachusetts, and other advocacy groups in a statewide coalition advocating for the
pregnancy standards law. This appears to explain why some counties have policies that
mirror the regulations but violate the law, including the widespread violations of the provision
on restraints during transportation back from the hospital. These regulations must be
changed. 103 CMR 924.17, published in July 2014.
12
World Health Organization, Technical Consultation on Postpartum and Postnatal Care, (2010).
available online.
13
For example, prior to September 2015, DOC policy violated, ignored, or had a mixed record on
almost all of the provisions dealing with the use of restraints. In response to advocacy from
Prisoners’ Legal Services, the DOC substantially revised its policy so that it complies with six
of eight key provisions.
14
In 2014, public opinion research found that people in Massachusetts favor prevention and
rehabilitation over the “tough-on-crime” policies they supported in the past. Two-thirds of
respondents support changing the criminal justice system to send fewer people to prison
instead of building new prisons. S. Koczela, R. Parr, B. Forman, Ready for Reform? Public
Opinion on Criminal Justice in Massachusetts (MassINC, 2014), p. 11. Estimated costs to
incarcerate one person for one year in a county jail or a state prison range from $37,000 to
$45,500. B. Forman and J. Larivee, Crime, Cost, and Consequences: Is It Time to Get Smart on
Crime? (MassINC, 2013), p. 12. Both reports are available online.

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BREAKING PROMISES: VIOLATIONS OF THE MASSACHUSETTS PREGNANCY STANDARDS & ANTI-SHACKLING LAW

“I’ve never been so uncomfortable in my
life... It’s just the reality that you have to
push for everything, all these things that
are so basic...
I shouldn’t have to struggle to pull up my
pants each day or get shoes that fit me.
Yeah, it’s jail, but I am sick of that excuse.
I am a human being.”