COVID-19 Public Health Considerations for Pregnant and Postpartum People Who Are Incarcerated
July 25, 2023
Prisons, jails, and juvenile and immigrant detention facilities are high-risk environments for the transmission of COVID-19 and other communicable diseases. Early in the pandemic, institutions of incarceration became hot-spots for infection, with higher case rates and COVID-related morbidity and mortality compared to the general population1–3. Many factors contribute to this increased risk, such as limited ability to practice social distancing, overcrowding, congregate housing and meals, daily flux of staff between the community and the institution, and variable access to adequate handwashing and cleaning supplies. Available data suggest that pregnant women with COVID-19 are at increased risk for more severe illness compared with nonpregnant women4–8. Compared to pregnant individuals without COVID-19, those with infection have higher risk of overall morbidity, intensive care unit admissions, mechanical ventilation, pre-eclampsia, preterm birth, newborn admission to the neonatal intensive care unit, and death8–10. Pregnant individuals with comorbidities such as obesity and gestational diabetes are at even higher risk for severe illness compared with the general population with similar comorbidities. Black and Hispanic individuals who are pregnant appear to have disproportionate COVID-19 infection and death rates4,7,8,11. Pregnant individuals in custody may have uniquely compounded and intersecting risk factors for developing severe COVID-19 illness. While vaccination has decreased frequency and severity of COVID-19, uptake among incarcerated individuals and pregnant individuals has been lower than non-incarcerated or non-pregnant individuals.
Given the convergent risks of incarceration and pregnancy for COVID-19 morbidity and mortality, the American College of Obstetricians and Gynecologists (ACOG) supports policies that reduce the likelihood of COVID-19 exposure and infection for pregnant people, including reducing crowding by an overall decrease of incarcerated populations, eliminating pretrial detention, promoting reduced and alternative sentencing for those convicted, and allocating resources to support alternatives to incarceration before, during, and after sentencing for all pregnant individuals. Below are recommendations for public officials, as well as health care practitioners and administrators:
- State, federal, and other public officials should exercise their full authority to keep pregnant people out of custody whenever possible and consistent with public safety. These officials and authorities should include, but are not limited to, the Federal Bureau of Prisons, governors, departments of corrections, parole boards, judges, sheriffs, attorneys general, prosecutors, county and city commissioners, and other elected officials. This includes avoiding arrest and confinement of pregnant individuals in favor of community-based alternatives and early return to the community for pregnant individuals who are currently incarcerated3.
- If a pregnant individual enters custody, local and state agencies and policy makers should partner with jails, prisons, and detention centers to ensure safe transition upon release. Such planning should include facilitating continuity of prenatal care, continuation of medication treatment for those with substance use disorder, and case management services to assist with housing, food, and other immediate needs12.
- For people who remain in custody, prisons, jails, and detention facilities should implement measures recommended by the CDC’s Guidance on Management of COVID-19 in Correctional and Detention Facilities and as recommended by guidance from the National Commission on Correctional Health Care13,14. CDC guidance emphasizes sound screening, housing, and hygiene measures, as well as promoting safe in-person visitation.
- Hospitals and health systems should develop care plans to ensure that when pregnant and postpartum people who are incarcerated come to their hospitals and clinics, they are treated with dignity and respect and retain the ability to exercise their rights.
- Institutions of incarceration must ensure that pregnant people have access to comprehensive evidence-based health care, including all recommended prenatal care (including fetal testing, ready access to triage visits, and substance use disorder treatment as indicated), abortion, postpartum care (including contraception if desired), and breastfeeding and breastmilk expression support, as well as timely assessment of pregnancy-related or COVID-19 symptoms, in accordance with ACOG guidance15,16. Barriers to accessing care within institutions, such as co-pays for incarcerated individuals, should be removed. In the event of rising local COVID-19 cases or threats from new pandemics, carceral facilities should adapt their operations to ensure these aspects of pregnancy and postpartum care. Telehealth services may be useful for some aspects of prenatal care when those services cannot be provided on-site and when travel off-site is not feasible or, due to community levels of COVID-19, may pose an exposure risk.
- There are occasions when medical isolation of a pregnant person infected with COVID-19 in custody is necessary in accordance with CDC guidelines. Institutions of incarceration must not use solitary confinement or other punitive restrictive housing arrangements for COVID-19 quarantine or medical isolation purposes, especially for pregnant and postpartum individuals.
Intersecting Inequities During the Pandemic
Special considerations for incarcerated pregnant people support release and avoiding confinement. Incarceration itself is a risk factor for acquiring COVID-19 and pregnant people in custody are more likely to become infected compared with pregnant people in the community. Pregnant people who are incarcerated have higher rates of underlying medical conditions, which increases risk for severe COVID-19 infection. Additionally, pregnancy confers an increased risk of severe COVID-19 illness and death. Finally, institutionalized racism and the pervasiveness of bias means that pregnant people who are incarcerated are more likely to be persons of color. Research has also shown disproportionate rates of COVID-19 morbidity among Black and Hispanic incarcerated individuals compared to white incarcerated individuals3. The combination of all these factors—incarceration, pregnancy, and institutionalized racism—creates an intersection in which pregnant people in custody are especially vulnerable to severe COVID-19 illness17.
Policies that were instituted by hospitals and health systems early in the pandemic to mitigate COVID-19 transmission may have disproportionate effects on pregnant people in custody during the labor, delivery, and postpartum periods. Examples were limitations on family visitation and policies that mandate, for COVID-19-positive people, infant separation after delivery; such restrictions negatively affect parent–infant bonding and eliminate the possibility of breastfeeding. These restrictions also can have long-term consequences for family building after release from prison, jail, or detention. Frequent misinterpretation, disregard, or lack of knowledge about the rights of pregnant and postpartum people who are incarcerated to accept or decline services such as COVID-19 testing or infant separation exacerbates the disproportionate effect of these policies. Hospitals and health systems should develop care plans, regardless of current or future pandemics, to ensure that pregnant and postpartum incarcerated patients at their hospitals and clinics are treated with dignity and respect and retain the ability to exercise their rights while hospitalized.
Pandemic-Related Systemic Strains Affect Prenatal and Postnatal Care
Even if a pregnant person who is incarcerated does not contract COVID-19, the strains of the COVID-19 pandemic on prisons, jails, and detention centers may have a deleterious effect on pregnancy and prenatal care16. One study by Kramer et al., of 17 prisons and jails reported variability in how facilities provided access to prenatal care amid attempts to minimize trips offsite18. As institutions responded to the increasing cases of COVID-19, their ability to provide routine and urgent pregnancy care was constrained at some institutions. Outside practitioners may be limited in their ability to provide on-site prenatal care due to travel restrictions and increased demand to provide care for infection in the community. Telehealth services, which became routine during the pandemic, may not be accessible to pregnant persons in custody. Additionally, if the institution’s own health care staff fall ill, provision of care for pregnant incarcerated people could be compromised. The ability to transport pregnant people offsite for routine prenatal care and time-sensitive care, such as abortion access, medication treatment for opioid use disorder, or urgent evaluation of labor symptoms, may be constrained as staff and operational resources are diverted to the increasing numbers of incarcerated COVID-19 patients. Additionally, options for breast milk expression and transporting breastmilk from incarcerated parents to infants’ caregivers are more limited due to COVID-19 travel restrictions. This precludes the known benefits of breastfeeding and bonding on maternal and infant health.
As institutions of incarceration adapt operations in response to the pandemic, they must ensure that pregnant people have access to comprehensive evidence-based health care, including all recommended prenatal care (including fetal testing, ready access to triage visits, and substance use disorder treatment as indicated), abortion, postpartum care (including contraception if desired), and breastfeeding and breastmilk expression support, as well as timely assessment of pregnancy-related or COVID-19 symptoms, in accordance with ACOG guidance15,16. Barriers to accessing care within institutions, such as co-pays for incarcerated individuals, should be removed.
Opposition to Use of Solitary Confinement
There are occasions when medical isolation of a pregnant person infected with COVID-19 in custody is necessary in accordance with CDC guidance. The 2022 Kramer et al., study reported that at least one facility used restrictive housing, also known as solitary confinement, for medical isolation and quarantine18. Solitary confinement, frequently used as a punitive measure in many jails, prisons, and detention facilities, should not be used for pregnant individuals19. Solitary confinement has known risks for pregnant individuals including, but not limited to, exacerbation of mental health conditions, difficulties accessing necessary medical attention for urgent pregnancy symptoms, and limited mobility. Limited mobility can increase the risk of life-threatening blood clots, which are more frequent in pregnancy and the postpartum period. In addition, solitary confinement may interfere with an incarcerated individual’s ability to complete court-mandated programs, which could extend sentences or affect custody arrangements. Therefore, solitary confinement should not be used in COVID-19 quarantine efforts. Staff at carceral facilities should become familiar with and implement recommendations for ethical medical isolation and quarantine including supervision of isolation/quarantine by medical professionals, removal from isolation as soon as medically cleared, transparency with the individual and family about isolation, and daily records of ongoing need for isolation/quarantine20.
The routine requirement of quarantine after offsite medical evaluation, also documented in the Kramer et al., study, may deter an incarcerated person from seeking necessary medical attention18. Policies that consider quarantine after an offsite appointment or after a hospitalization should be implemented judiciously. For instance, quarantining a postpartum person after hospitalization for childbirth should be considered in the context that the person was tested for COVID-19 upon admission to the hospital, and if the individual tested negative throughout their hospitalization, they may not require quarantine upon return to prison or jail. Additionally, the use of telehealth services can mitigate the need for offsite travel to routine appointments and therefore decrease potential need for quarantine.
COVID-19 Vaccination Considerations
Racism within the health care and carceral systems creates particular ethical complexities when considering public and individual health interventions such as vaccination21. Efforts to administer the COVID-19 vaccine to people who are incarcerated, either within an emergency use authorization or after FDA approval, must consider the decades of unethical vaccination trials conducted without informed consent in carceral facilities in the United States22. Simultaneously, the elevated COVID-19 risks for people who are incarcerated as well as carceral power dynamics that may affect individual autonomy highlight the importance of ensuring the inclusion of individuals who are incarcerated in COVID-19 vaccination planning23. The American College of Obstetricians and Gynecologists supports access to the COVID-19 vaccine for pregnant individuals who are incarcerated in a manner that prioritizes autonomy and informed consent of the individual considering vaccination. See the ACOG Practice Advisory on Vaccinating Pregnant and Lactating Patients against COVID-19 for specific clinical recommendations.
The American College of Obstetricians and Gynecologists is committed to the health and well-being of pregnant individuals, including those who are incarcerated. The American College of Obstetricians and Gynecologists recognizes that prisons, jails, and detention centers have high rates of COVID-19 infection. This poses specific and unique concerns for the health and safety of incarcerated pregnant individuals, and ACOG, therefore, supports efforts that reduce the number of pregnant individuals in custody while maintaining uncompromised access to pregnancy and postpartum care for those who remain incarcerated.
- Jiménez MC, Cowger TL, Simon LE, Behn M, Cassarino N, Bassett MT. Epidemiology of COVID-19 among incarcerated individuals and staff in Massachusetts jails and prisons. JAMA Netw Open 2020; 3 :e2018851. doi: 10.1001/jamanetworkopen.2020.18851.
- Saloner B, Parish K, Ward JA, DiLaura G, Dolovich S. COVID-19 cases and deaths in federal and state prisons. JAMA 2020; 324: 602-3. doi: 10.1001/jama.2020.12528.
- Li MY, Grebbin S, Patil A, Cowger TL, Kunichoff D, Feldman J, Jiménez MC. Examining COVID-19 mortality rates by race and ethnicity among incarcerated people in 11 U.S. state prisons (March-October 2021). SSM Popul Health. 2022; 20: 101299. doi: 10.1016/j.ssmph.2022.101299.
- Ellington S, Strid P, Tong VT, Woodworth K, Galang RR, Zambrano LD, et al. Characteristics of women of reproductive age with laboratory-confirmed SARS-CoV-2 infection by pregnancy status - United States, January 22-June 7, 2020. MMWR Morb Mortal Wkly Rep 2020; 69: 769-75. doi: 10.15585/mmwr.mm6925a1.
- Collin J, Byström E, Carnahan A, Ahrne M. Public Health Agency of Sweden's brief report: pregnant and postpartum women with severe acute respiratory syndrome coronavirus 2 infection in intensive care in Sweden. Acta Obstet Gynecol Scand 2020; 99: 819-22. doi: 10.1111/aogs.13901.
- Delahoy MJ, Whitaker M, O'Halloran A, Chai SJ, Kirley PD, Alden N, et al. Characteristics and maternal and birth outcomes of hospitalized pregnant women with laboratory-confirmed COVID-19 - COVID-NET, 13 states, March 1-August 22, 2020. COVID-NET Surveillance Team. MMWR Morb Mortal Wkly Rep 2020; 69: 1347-54. doi: 10.15585/mmwr.mm6938e1.
- Panagiotakopoulos L, Myers TR, Gee J, Lipkind HS, Kharbanda EO, Ryan DS, et al. SARS-CoV-2 infection among hospitalized pregnant women: reasons for admission and pregnancy characteristics - eight U.S. health care centers, March 1-May 30, 2020. MMWR Morb Mortal Wkly Rep 2020; 69: 1355-9. doi: 10.15585/mmwr.mm6938e2.
- Zambrano LD, Ellington S, Strid P, Galang RR, Oduyebo T, Tong VT, et al. Update: characteristics of symptomatic women of reproductive age with laboratory-confirmed SARS-CoV-2 infection by pregnancy status - United States, January 22-October 3, 2020. CDC COVID-19 Response Pregnancy and Infant Linked Outcomes Team. MMWR Morb Mortal Wkly Rep 2020; 69: 1641-7. doi: 10.15585/mmwr.mm6944e3
- Thoma ME, Declercq ER. All-cause maternal mortality in the US before vs during the COVID-19 Pandemic. JAMA Netw Open 2022; 5: e2219133. doi: 10.1001/jamanetworkopen.2022.19133.
- Boettcher LB, Metz TD. Maternal and neonatal outcomes following SARS-CoV-2 infection. Semin Fetal Neonatal Med 2023; 28: 101428. doi: 10.1016/j.siny.2023.101428.
- Knight M, Bunch K, Vousden N, Morris E, Simpson N, Gale C, et al. Characteristics and outcomes of pregnant women admitted to hospital with confirmed SARS-CoV-2 infection in UK: national population-based cohort study. UK Obstetric Surveillance System SARS-CoV-2 Infection in Pregnancy Collaborative Group. BMJ 2020; 369: m2107. doi: 10.1136/bmj.m2107.
- National Academies of Sciences, Engineering, and Medicine. Decarcerating correctional facilities during COVID-19: advancing health, equity, and safety. National Academics Press; 2020. Accessed July 20, 2023. https://nap.nationalacademies.org/catalog/25945/decarcerating-correctional-facilities-during-covid-19-advancing-health-equity-and
- Centers for Disease Control and Prevention. Guidance on management of COVID-19 in homeless service sites and in correctional and detention facilities. CDC; 2023. Accessed July 20, 2023. https://www.cdc.gov/coronavirus/2019-ncov/community/homeless-correctional-settings.html
- National Commission on Correctional Health Care. COVID-19 resources. Accessed July 20, 2023. https://www.ncchc.org/position-statements/covid-19-resources
- Opioid use and opioid use disorder in pregnancy. Committee Opinion No. 711. American College of Obstetricians and Gynecologists. Obstet Gynecol 2017; 130: e81-94. doi: 10.1097/AOG.0000000000002235.
- Reproductive health care for incarcerated pregnant, postpartum, and nonpregnant individuals. ACOG Committee Opinion No. 830. American College of Obstetricians and Gynecologists. Obstet Gynecol 2021; 138: e24-34. doi: 10.1097/AOG.0000000000004429.
- Centers for Disease Control and Prevention. Risk for COVID-19 infection,
hospitalization, and death by race/ethnicity. CDC; 2021. Accessed July 20, 2023. https://stacks.cdc.gov/view/cdc/105453.
- Kramer C, Williamston AD, Shlafer RJ, Sufrin CB. COVID-19's effect on pregnancy care for incarcerated people. Health Equity 2022; 6: 406-11. doi: 10.1089/heq.2022.0035.
- National Commission on Correctional Health Care. Solitary confinement (isolation). Position Statement. NCCHC; 2016. Accessed July 20, 2023. https://www.ncchc.org/position-statements/solitary-confinement-isolation-2016/
- Cloud D, Augustine D, Ahalt C, Williams B. The ethical use of medical isolation - not solitary confinement – to reduce COVID-19 transmission in correctional settings. University of California San Francisco, Amend; 2020. Accessed July 20, 2023. https://amend.us/wp-content/uploads/2020/04/Medical-Isolation-vs-Solitary_Amend.pdf
- Wang EA, Zenilman J, Brinkley-Rubinstein L. Ethical considerations for COVID-19 vaccine trials in correctional facilities. JAMA 2020; 324: 1031-2. doi: 10.1001/jama.2020.15589.
- Lerner BH. Subjects or objects? Prisoners and human experimentation. N Engl J Med 2007; 356: 1806-7. doi: 10.1056/NEJMp068280.
- Strassle C, Jardas E, Ochoa J, Berkman BE, Danis M, Rid A, et al. Covid-19 vaccine trials and incarcerated people - the ethics of inclusion. N Engl J Med 2020; 383: 1897-9. doi: 10.1056/NEJMp2025955.