Improving antenatal care in prisons

Perspectives Significant progress is being made to improve the outcomes of pregnancy and childbirth in many countries. In many low-and middle-income countries, including Ethiopia, Bangladesh, Bolivia (the Plurinational State of), Myanmar and Pakistan, great strides have been made in significantly reducing maternal mortality. 1 However, the estimated 24 000–60 000 women who are pregnant and incarcerated worldwide often lack access to antenatal care at the same level as that available in their communities. 2 Despite clear international standards that mandate equivalent care for people in prison, pregnant women in these settings face significant barriers to adequate antenatal care. The needs of pregnant women are often overlooked in prisons designed to house men – who comprise most of the world's prison population of over 10.1 million people. As the World Health Organization's Member States consider the post-2015 agenda for maternal health, this vulnerable and hidden cohort of women should not be forgotten. The first challenge to provision of adequate antenatal care in prisons is the location of correctional health systems within ministries of the interior or other security authorities. These institutions have large structures dedicated to maintaining security and health care providers tend to be marginalized in such settings. Many women, including those who are pregnant, are held in settings without access to toilets or water for washing or bathing and sleeping quarters often require sleeping on hard surfaces without a mattress or pillow. 7 The use of shackles and other restraints create significant discomfort and stress for women throughout pregnancy and especially during labour. 8 Most correctional settings lack dedicated obstetricians or skilled antenatal specialists. Because the basic medical services available to prisoners often do not include physical examination and reproductive history, women who need referral are not always identified. Women who can afford to pay for care may be the only ones to receive antenatal services in prison. A second challenge to the provision of antenatal care for women in prisons is the high rates of pre-existing conditions that affect maternal health, including sexually transmitted infections, hepatitis, mental illness and substance abuse. 9–13 Consequently, pregnant women in prison often need coordinated antenatal, medical and behavioural health services. Women infected with human immunodeficiency virus (HIV) and/or affected by opiate dependency are routinely denied safe, effective treatments for these conditions when pregnant, often due to a lack of educated health staff. A third barrier to adequate antenatal care is the pervasiveness …