Pregnant and postnatal women in prison: a Q&A

We spoke to Miranda Davies, author of our new report on female prisoners' use of hospital services, and Kirsty Kitchen of Birth Companions. What is prison like for pregnant and postnatal women and what can be done to improve things?


Published: 21/07/2022

The new Nuffield Trust report on prisoner health explores key health care issues for women in prison, with some of the main concerns identified around pregnant and postnatal women. Can you please give us a summary of what you’ve found?

MD: After our earlier studies on prisoners’ use of hospital care and the health care challenges they face, we wanted to understand the unique experiences of women in prison. To do this, we looked at over 1,000 hospital admissions and just under 9,000 outpatient appointments by women in prison in 2019/20.

We found that the specific and serious health needs of pregnant women and new mothers in hospitals are not always being met, which is putting women and their children at significant risk. Our data shows that pregnant women in prisons in England experience higher rates of premature labour than women in the general population, which is particularly worrying as babies born preterm have a higher mortality rate and an increased risk of disability.

We also found out that 109 women had given birth in the two years before arriving in prison. For those women, there are a lot of unknowns about what needs they have if they have been separated from their child, with the same clearly being true for the child.  

Between July 2020 and March 2021, we also know there were 31 prisoners in England who gave birth. While 29 of those births took place in hospital, two women gave birth on the way to hospital in an ambulance, which we don't want to see happening.

What do you think are the risks to pregnant prisoners and their newborn children as things stand?

MD: People in prison are entitled to health care just like they are in the community, but pregnant women in prison are missing their standard midwifery and obstetrics care appointments. That is an opportunity to catch things early, which is what we want to see happening to avoid preterm labour. As it stands over 30% of obstetric appointments are being missed.

KK: Miscarriage risks are very high. Women report pressing their cell buzzers because they’re bleeding and know that they're pregnant, and yet the response is slow, and they don’t always get seen by a midwife or taken to hospital as they should. Many are deeply fearful of giving birth in their cell behind a locked door. Whether that does or doesn't eventually happen, it takes a huge toll; toxic stress is a known issue for foetal development and long-term child development.

Why are prisons so ill equipped to provide care for pregnant and new mothers?

MD: The primary purpose of prisons is not health, so it will always take a back seat to other considerations. You will always have to go through different layers before getting to any sort of health assistance. Security is always the primary concern. We see that with prisoners having to be escorted to health care appointments. If there are not enough prison staff, that appointment will be missed.

KK: NHS Health and Justice services, which are responsible for commissioning and delivering health care in prisons, have now reclassified every pregnancy in prison as a high-risk pregnancy. That's a big step forward in starting to recognise the impact of the system on delivering equivalence of health care, which is meant to be baked into the prison system that we have, but which we actually know is impossible to achieve in that environment.

To what extent can a prison ever be an appropriate setting for a pregnant woman?

KK: Prison will never be an appropriate or safe place for pregnancy. It isn't an appropriate, safe or effective place for women in general, and that's been recognised by the government in the Female Offender Strategy. Once you add the fast-changing and particular nature of women's needs during pregnancy and early motherhood into the mix, it is impossible for that system to be appropriate or safe.

MD: There are a lack of honest conversations about the difficulties of caring for people in prison, probably due to our perceptions of prison and the criminal justice system being embedded from a young age. It's an easy win for people to think these are all black and white issues, that everyone in prison is bad and that they should be treated in a particular way. Most people in the general population hope that people who go to prison come out less likely to reoffend, but we know that isn't the case.

Is there a country that we should be modelling ourselves on?

KK: There are a lot of countries doing far better on it. England really is an outlier. There are 11 other countries that either prevent the imprisonment of pregnant women, or restrict it so severely that it is only in very exceptional circumstances that a pregnant woman can be imprisoned. Those include Russia, Mexico, Colombia and Brazil. We are imprisoning pregnant women at a rate most countries would never accept.

What might more appropriate support for pregnant and new mothers in prison look like?

KK: We will now have dedicated, virtually full-time midwives in prisons, with a specialist level of knowledge and skill. That is a huge leap forwards. Added to the Pregnancy Mother and Baby Liaison Officer (another recently introduced role), this means there will be a prison-based and a health-based anchor role in every prison, which has the potential to drive a lot of improvement. Specialist peer support programmes within prison are also delivering huge amounts of value.

MD: There’s an increasing drive to include the voices of women in prison and women with lived experience of prison as part of any improvements. It's really important that happens, without it just being lip service, and it actually takes on board the experiences of people who have been there – not just to support other women in prison but also to drive improvements more generally.

What else can be done to improve things?

KK: We need a culture of learning. There are significant problems with the culture in maternity services in the community, as the Ockenden review showed, but there are really huge problems with it in the prison system. We need a level of acceptance that things are going wrong and will continue to go wrong. And they have to be acknowledged, shared, talked about and learned from.

MD: We need to have lived experience voices at strategic levels. It's fine having a panel and listening to their experiences, but it shouldn't just be about having stories from women about awful things that have happened to them, even if that is important in itself. We have to make sure women are included in a meaningful way.

When you read the report about the baby who died at HMP Bronzefield, the woman is described as “difficult, challenging, uncooperative”. That’s often the mindset at the start – essentially 'these are terribly challenging people just not doing what they're supposed to do'. We must somehow overcome that.

Would you be surprised if there was another incident like the ones at HMP Bronzefield (where a baby died after a prisoner gave birth alone in a cell) and HMP Styal (where a prisoner gave birth to a stillborn baby in the toilet of a cell)?

MD: Even the most recent data shows that it's a real possibility. You have 10% of women prisoners giving birth outside of hospital, so no I wouldn’t be surprised.

KK: I'll be devastated if it happens again, but I wouldn't be surprised at all. We hear of so many serious incidents and near misses, I'm more surprised that we haven't had more deaths. There are a lot of individuals in the system doing their absolute best and holding things together, like prison officers, midwives and prison nurses. There is great work happening in spite of the system, rather than because of it.

We have in the past highlighted data collection worries on prisoner health. How would you describe what we know by now about women in prison, and by extension pregnant women, from that perspective?

KK: The problems with data on this issue have been running on for decades – the speed of change on it has been glacial. We need to know how many miscarriages are happening, how many stillbirths, how many ectopic pregnancies, how many neonatal deaths – there is no reason why we can't have that information. You cannot commission and deliver appropriate services for women without it.

MD: There is now momentum to improve things, and there is at least now reporting which shows that pregnant women exist. The data is still limited, and there are ways it could be further improved, but it has got better. Often when you speak to policy-makers about the challenges of women entering prison, they will say “yes, but we don't have firm data on that”, or “there isn’t enough evidence of that”. On that there is a role we can play, because we've got a large dataset that we can look at in a standardised way over time.

What are the consequences on wider society of not getting support for pregnant prisoners and new mothers right?

KK: There are huge consequences, because you are perpetuating an intergenerational cycle of disadvantage. Having a parent in prison, and/or being separated from your mother in the early stage of your life, are two of the strongest indicators for future disadvantage, as well as entry into the criminal justice system yourself, and/or entry into the care system. In the way that our society works, where you start from is one of the strongest indicators of where you will end up.

How do you want the findings from our report to deliver changes to policy?

KK: There is a huge issue in sentencers believing that, because we have this principle of equivalence of health care in the prison system, as a prisoner you will receive the same level and quality of care as you would in the community. It's really important to have evidence like the Nuffield Trust report to correct that thinking, and to show the very real consequences of sending a pregnant woman into prison.

MD: One of our key findings is that premature birth rates are higher for pregnant women in prison, which hopefully can be used as a piece of evidence to demonstrate there are other ways that would keep women safer. That's something most people would struggle to disagree with, despite the politics of the situation. If we can point to evidence that shows that something really isn’t working, and that was then considered at sentencing, it would be a really positive impact.