Pregnant and Postpartum People Who Are Incarcerated During the COVID-19 Pandemic
January 27, 2021
Prisons, jails, and juvenile and immigrant detention facilities are high-risk environments for the transmission of COVID-19, with cases rapidly rising in these settings. Incarceration is a known risk factor for acquiring COVID-191, and individuals in prisons are three times more likely to die from COVID-19 than nonincarcerated individuals2, 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 women 4–8. Specifically, these data indicate a small, but significant, risk of intensive care unit admissions, mechanical ventilation, and death in pregnant women with symptomatic COVID-19 infection when compared with nonpregnant symptomatic women8. Pregnant individuals with comorbidities such as obesity and gestational diabetes may be 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, 7–9. Given the growing evidence of risk for pregnant individuals, the Centers for Disease Control and Prevention (CDC) now includes pregnant women in its “increased risk” category for COVID-19 illness. Pregnant individuals in custody may have uniquely compounded and intersecting risk factors for developing severe COVID-19 illness.
- 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. 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 appropriate housing to quarantine individuals upon return to the community, 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 needs3.
- For people who remain in custody, prisons, jails, and detention facilities should implement measures for social distancing and provide access to face masks, hand washing and other hygiene practices, safe housing arrangements, and other practices as outlined by the CDC’s Interim Guidance on Management of COVID-19 in Correctional and Detention Facilities10 and as recommended by guidance from the National Commission on Correctional Health Care11.
- 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.
- 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 guidance 12, 13. Barriers to accessing care within institutions, such as co-pays for incarcerated individuals, should be removed.
- There are occasions when medical isolation or quarantine of a pregnant person exposed to or 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.
- Telehealth services, which are already used widely during the pandemic, can mitigate the need for offsite travel to routine appointments and can facilitate access to prenatal care and decrease a potential need for quarantine.
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. 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 illness14.
Current policies instituted by hospitals and health systems to mitigate COVID-19 transmission may have disproportionate effects on pregnant people in custody during the labor, delivery, and postpartum periods. This includes 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 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 are likely to have a deleterious effect on pregnancy and prenatal care13. As institutions respond to the increasing cases of COVID-19, their ability to provide routine and urgent pregnancy care is constrained. 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 have become routine during the pandemic, may not be accessible to a pregnant person in custody. Additionally, if the institution’s own health care staff fall ill, provision of care for pregnant incarcerated people is 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, is 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 guidance12, 13. 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 quarantine or medical isolation of a pregnant person infected with or exposed to COVID-19 in custody is necessary in accordance with CDC guidance. Solitary confinement, frequently used as a punitive measure in many jails, prisons, and detention facilities, should not be used for pregnant individuals15. 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/quarantine16.
The routine requirement of quarantine after offsite medical evaluation may deter an incarcerated person from seeking necessary medical attention. 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 vaccination17. 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 States18. 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 planning19. 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 at https://www.acog.org/clinical/clinical-guidance/practice-advisory/articles/2020/12/vaccinating-pregnant-and-lactating-patients-against-covid-19.
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.
- 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.
- National Academies of Sciences, Engineering, and Medicine. Decarcerating correctional facilities during COVID-19: advancing health, equity, and safety. Washington, DC: The National Academies Press; 2020. Available at: https://www.nap.edu/catalog/25945/decarcerating-correctional-facilities-during-covid-19-advancing-health-equity-and. Retrieved February 16, 2021.
- 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.
- 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.
- 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.
- 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.
- 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. Available at: https://www.cdc.gov/mmwr/volumes/69/wr/mm6944e3.htm?s_cid=mm6944e3_w. Retrieved February 16, 2021.
- 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. Available at: https://www.bmj.com/content/369/bmj.m2107.long. Retrieved February 16, 2021.
- Centers for Disease Control and Prevention. Interim guidance on management of coronavirus disease 2019 (COVID-19) in correctional and detention facilities. Atlanta, GA: CDC; 2020. Available at: https://www.cdc.gov/coronavirus/2019-ncov/community/correction-detention/guidance-correctional-detention.html. Retrieved February 16, 2021.
- National Commission on Correctional Health Care. COVID-19 coronavirus: what you need to know in corrections. Available at: https://www.ncchc.org/covid-resources. Retrieved February 16, 2021.
- Opioid use and opioid use disorder in pregnancy. Committee Opinion No. 711. American College of Obstetricians and Gynecologists. Obstet Gynecol 2017;130:e81-94.
- Health care for pregnant and postpartum incarcerated women and adolescent females. Committee Opinion No. 511. American College of Obstetricians and Gynecologists. Obstet Gynecol 2011;118:1198-202.
- Centers for Disease Control and Prevention. COVID-19 hospitalization and death by race/ethnicity. Atlanta, GA: CDC; 2020. Available at: https://www.cdc.gov/coronavirus/2019-ncov/covid-data/investigations-discovery/hospitalization-death-by-race-ethnicity.html. Retrieved February 16, 2021.
- National Commission on Correctional Health Care. Solitary confinement (isolation). Position Statement. Chicago, IL: NCCHC; 2016. Available at: https://www.ncchc.org/solitary-confinement. Retrieved February 16, 2021.
- University of California San Francisco, Amend. COVID-19 in correctional facilities: medical isolation. Available at: https://amend.us/covid-19-in-correctional-facilities-medical-isolation. Retrieved February 16, 2021.
- Wang EA, Zenilman J, Brinkley-Rubinstein L. Ethical considerations for COVID-19 vaccine trials in correctional facilities. JAMA 2020;324:1031-2. Available at: https://jamanetwork.com/journals/jama/fullarticle/2769694. Retrieved February 16, 2021.
- Lerner BH. Subjects or objects? Prisoners and human experimentation. N Engl J Med 2007;356:1806-7. Available at: https://www.nejm.org/doi/10.1056/NEJMp068280. Retrieved February 16, 2021.
- 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. Available at: https://www.nejm.org/doi/10.1056/NEJMp2025955. Retrieved February 16, 2021.