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.¹1. Hogan MC, Foreman KJ, Naghavi M, Ahn SY, Wang M, Makela SM, et al. Maternal mortality for 181 countries, 1980-2008: a systematic analysis of progress towards Millennium Development Goal 5. Lancet. 2010 May 8;375(9726):1609-23. http://dx.doi.org/10.1016/S0140-6736(10)60518-1 PMID:20382417
http://dx.doi.org/10.1016/S0140-6736(10)... 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. ²2. Walmsley R. World female imprisonment list. Colchester: International Centre for Prison Studies; 2012. Available from: Available from: http://www.prisonstudies.org/sites/default/files/resources/downloads/wfil_2nd_edition.pdf [cited 2015 July 2].
http://www.prisonstudies.org/sites/defau... Despite clear international standards that mandate equivalent care for people in prison, pregnant women in these settings face significant barriers to adequate antenatal care. ³3. Møller L, Stöver H, Jürgens R, Gatherer A, Nikogosian H. Health in prisons: A WHO guide to the essentials of prison health. Copenhagen: WHO Regional Office for Europe; 2007. Available from: Available from: http://www.euro.who.int/__data/assets/pdf_file/0009/99018/E90174.pdf?ua=1 [cited 2015 August 31].
http://www.euro.who.int/__data/assets/pd... ⁵5. Walker JR, Hilder L, Levy MH, Sullivan EA. Pregnancy, prison and perinatal outcomes in New South Wales, Australia: a retrospective cohort study using linked health data. BMC Pregnancy Childbirth. 2014;14(1):214. http://dx.doi.org/10.1186/1471-2393-14-214 PMID:24968895
http://dx.doi.org/10.1186/1471-2393-14-2... 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. ³3. Møller L, Stöver H, Jürgens R, Gatherer A, Nikogosian H. Health in prisons: A WHO guide to the essentials of prison health. Copenhagen: WHO Regional Office for Europe; 2007. Available from: Available from: http://www.euro.who.int/__data/assets/pdf_file/0009/99018/E90174.pdf?ua=1 [cited 2015 August 31].
http://www.euro.who.int/__data/assets/pd... ⁶6. Walmsley R. World prison population list.; Colchester: International Centre for Prison Studies 2011. Available from: Available from: http://www.prisonstudies.org/sites/default/files/resources/downloads/wfil_2nd_edition.pdf [cited 2015 July 30].
http://www.prisonstudies.org/sites/defau... 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.⁷7. van den Bergh BJ, Gatherer A, Fraser A, Moller L. Imprisonment and women's health: concerns about gender sensitivity, human rights and public health. Bull World Health Organ. 2011 Sep 1;89(9):689-94. http://dx.doi.org/10.2471/BLT.10.082842 PMID:21897490
http://dx.doi.org/10.2471/BLT.10.082842... The use of shackles and other restraints create significant discomfort and stress for women throughout pregnancy and especially during labour. ⁸8. The shackling of incarcerated pregnant women: a human rights violation committed regularly in the United States. Chicago: International Human Rights Clinic, University of Chicago Law School; 2013. Available from: Available from: https://ihrclinic.uchicago.edu/sites/ihrclinic.uchicago.edu/files/uploads/Report%20-%20Shackling%20of%20Pregnant%20Prisoners%20in%20the%20US.pdf [cited 2014 Dec 2].
https://ihrclinic.uchicago.edu/sites/ihr... 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. ⁹9. Lopes F, Latorre MR, Campos Pignatari AC, Buchalla CM. [HIV, HPV, and syphilis prevalence in a women's penitentiary in the city of São Paulo, 1997-1998]. Cad Saude Publica. 2001 Nov-Dec;17(6):1473-80. http://dx.doi.org/10.1590/S0102-311X2001000600031 PMID:11784908 Portuguese.
http://dx.doi.org/10.1590/S0102-311X2001... ¹³13. Fazel S, Baillargeon J. The health of prisoners.. Lancet 2011 Mar 12;377(9769):956-65. http://dx.doi.org/10.1016/S0140-6736(10)61053-7 PMID:21093904
http://dx.doi.org/10.1016/S0140-6736(10)... Consequently, pregnant women in prison often need coordinated antenatal, medical and behavioural health services. ¹⁴14. Reproductive Health Care for Incarcerated Women and Adolescent Females [Committee opinion]. Washington: American College of Obstetrics and Gynecology; 2012. Available from: Available from: http://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Health-Care-for-Underserved-Women/Reproductive-Health-Care-for-Incarcerated-Women-and-Adolescent-Females [cited 2014 Dec 2].
http://www.acog.org/Resources-And-Public... ¹⁵15. Caring for childbearing prisoners [Position statement]. London: Royal College of Midwives; 2011 Oct. Available from: Available from: https://www.rcm.org.uk/sites/default/files/POSITION%20STATEMENT%20Caring~ildbearing%20Prisoners_0.pdf [cited 2014 Dec 2].
https://www.rcm.org.uk/sites/default/fil... 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 of sexual assault and other human rights abuses in correctional settings. ¹⁶16. Enggist S, Moller L, Galea G, Udesen C. Prisons and health. Copenhagen: World Health Organization Regional Office for Europe; 2014. ¹⁷17. Todrys KW, Amon JJ. Health and human rights of women imprisoned in Zambia. BMC Int Health Hum Rights. 2011;11(1):8. http://dx.doi.org/10.1186/1472-698X-11-8 PMID:21696625
http://dx.doi.org/10.1186/1472-698X-11-8... Women endure high rates of physical and sexual assault in prison. ⁸8. The shackling of incarcerated pregnant women: a human rights violation committed regularly in the United States. Chicago: International Human Rights Clinic, University of Chicago Law School; 2013. Available from: Available from: https://ihrclinic.uchicago.edu/sites/ihrclinic.uchicago.edu/files/uploads/Report%20-%20Shackling%20of%20Pregnant%20Prisoners%20in%20the%20US.pdf [cited 2014 Dec 2].
https://ihrclinic.uchicago.edu/sites/ihr... Female prisoners may be forced into coercive sexual relationships to receive basic medical services, family visits or even food. ¹⁶16. Enggist S, Moller L, Galea G, Udesen C. Prisons and health. Copenhagen: World Health Organization Regional Office for Europe; 2014. Another concern is the practice of so-called virginity testing, used in some settings for women entering prison. ¹⁹19. Egypt: Military impunity for violence against women. New York: Human Right Watch; 2012. Available from: Available from: http://www.hrw.org/news/2012/04/07/egypt-military-impunity-violence-against-women [cited 2014 Dec 2].
http://www.hrw.org/news/2012/04/07/egypt... This practice amounts to sexual assault, even if performed by medical staff at the direction of security staff. The resulting physical and psychological trauma directly harms women and contributes to distrust of whatever antenatal care is available, especially when health staff are seen to be aligned with the security services.

A fourth issue is the lack of reliable data. Most prison health systems are separated from the ministry of health or public health department and do not report pregnancies, live births or complications in the population they serve. This lack of information is a barrier to improving - or tracking changes in - conditions.

We propose three responses to these challenges. First, the same reporting metrics used in public health agencies should be applied to prisons. Similar strategies have been adopted for reporting of deaths in custody and the development of risk reduction policies. ²⁰20. Deaths in custody reporting program (DCRP) [Internet]. Washington: U.S. Bureau of Justice Statistics; 2015. Available from: Available from: http://www.bjs.gov/index.cfm?ty=dcdetail&iid=243 [cited 2014 Dec 2].
http://www.bjs.gov/index.cfm?ty=dcdetail... Basic information includes rates and causes of death and injuries, hospital transfers and the prevalence of chronic disease.

Second, national policies designed to improve the reporting of sexual abuse and other human rights abuses should include women in prisons. ²¹21. Dumond RW. Confronting America's most ignored crime problem: the Prison Rape Elimination Act of 2003. J Am Acad Psychiatry Law. 2003;31(3):354-60. PMID:14584536 ²²22. Beck A, Berzofsky M, Casper R, Krebs C. Sexual victimization in prisons and jails reported by inmates, 2011-12.; Washington: U.S. Bureau of Justice Statistics 2013.

Third, successful programmes to reduce maternal mortality should be implemented in prisons. Two approaches that have been successful in Pakistan include prenatal health education in facilitator-led women's groups and training traditional birth attendants in infection control and emergency obstetric care. ²³23. Kidney E, Winter HR, Khan KS, Gülmezoglu AM, Meads CA, Deeks JJ, et al. Systematic review of effect of community-level interventions to reduce maternal mortality.. BMC Pregnancy Childbirth 2009;9(1):2. http://dx.doi.org/10.1186/1471-2393-9-2 PMID:19154588
http://dx.doi.org/10.1186/1471-2393-9-2... These types of interventions are a cost-effective means to improving maternal outcomes and could help integrate prison health services with those provided to the community. ²⁴24. Bartlett L, Weissman E, Gubin R, Patton-Molitors R, Friberg IK. The impact and cost of scaling up midwifery and obstetrics in 58 low- and middle-income countries. PLoS ONE. 2014;9(6):e98550. http://dx.doi.org/10.1371/journal.pone.0098550 PMID:24941336
http://dx.doi.org/10.1371/journal.pone.0... ²⁵25. Augood C, Newburn M, Thomas K. NCT antenatal sessions at Styal Prison. London: National Childbirth Trust; 2009. Available from: Available from: http://www.nct.org.uk/sites/default/files/related_documents/NCT%20antenatal%20sessions%20Styal%20Prison%20evaluation_0.pdf [cited 2014 Dec 2].
http://www.nct.org.uk/sites/default/file...

Improving antenatal care in prisons is important for improving maternal outcomes in all countries. New strategies that have emerged from discussions of the post-2015 development agenda include forging new partnerships and identifying and integrating vulnerable populations. ²⁶26. United Nations Task Team on the Post-2015 UN Development Agenda. A renewed global partnership for development. New York: United Nations; 2013. Available from: Available from: http://www.un.org/en/development/desa/policy/untaskteam_undf/glob_dev_rep_2013.pdf [cited 2014 Dec 2].
http://www.un.org/en/development/desa/po...

Acknowledgement

Homer Venters is also affiliated with the New York University Langone Medical School, Center for Health and Human Rights, New York, USA.

References

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