Demographic characteristics of survey and interview participants are summarized in Table 1. The gender, race, ethnicity, and number of years worked as a CO for the participants in this study generally reflected the demographics of the total CO population at the prison (Bosch, G., personal communication, May 20, 2019). Most COs who completed the survey (58%) reported having attended a birth in their role as a CO. The number of births attended over their tenure ranged widely, but most COs had attended five births or less (Range = 0–50, Median = 3).
Compared to the survey sample, interview participants were more likely to be women, older in age, and had a lower level of post-secondary education. COs who participated in the interviews had worked as COs from 3 to 28 years (M = 14 years, Median = 14.5 years). COs who participated in the interviews reported attending a wide-ranging number of births (Range = 0–40; Median = 2).
Survey participants’ knowledge of policies and programs for pregnant women
A majority of COs who completed the survey identified that MCH policies and programs were available to pregnant women at the prison (see Fig. 1). COs had less awareness of some specific MCH programs; relatively fewer COs were aware of pregnant women’s access to abortion counseling and services (54%) or breastfeeding support (46%). Although 92% of COs reported they were aware of the prison doula program, more than one-third (38%) reported they were “not at all familiar” with the specifics of the program.
In the survey, COs were asked if they had received training about select topics specific to meeting the unique needs of pregnant women in prison (see Fig. 1). A majority of COs responded that they received training about safely transporting pregnant women to the hospital for medical appointments and delivery (79%) and training on maintaining safety at the hospital during labor and delivery (68%). Fewer COs responded they had received training on the programs specifically available to pregnant women (50%) and fewer than half reported they had received information or training about the prison doula program (38%).
Survey participants’ perceptions of policies and programs for pregnant women
Most COs had favorable perceptions of the treatment pregnant women received at the prison. A majority (76%) of COs agreed or strongly agreed that the prison’s “policies regarding the treatment of pregnant offenders are comprehensive;” 82% agreed or strongly agreed that the prison’s “policies regarding the treatment of pregnant offenders are fair.” COs generally perceived the health care at the prison to be high quality; 84% of COs agreed or strongly agreed that the prison “provides the same standard of care or better care for pregnant offenders as the care non-incarcerated women would receive.”
The survey results indicated that COs held mixed views about the type of treatment pregnant women should receive compared to non-pregnant women. About half (45%) of COs agreed or strongly agreed that “pregnant women should not be treated any differently than other women in prison;” in contrast, about one-third (34%) disagreed or strongly disagreed with this statement. Similarly, COs were divided on their responses to the statement “I believe pregnant offenders deserve special accommodations in prison,” with 42% expressing agreement and 40% expressing disagreement. Despite these mixed views about the general treatment of pregnant women in prison, COs expressed support and positive perceptions of specific policies and programs that accommodate the needs of pregnant women. For example, the majority of COs (76%) disagreed or strongly disagreed that pregnant women should be restrained during labor and delivery. COs also expressed generally positive perceptions of the prison doula program’s impact on pregnant women, infants, and COs themselves (see Fig. 2).
Qualitative themes from interviews
From the interviews, five major themes regarding COs’ perceptions of MCH policies and programs were identified: 1) COs recognized that pregnancy poses a unique challenge to maintaining professional boundaries in prison; 2) COs perceived the prison doula program as benefitting pregnant women, infants, and their own work as COs; 3) Lack of training about the prison doula program made COs’ jobs more difficult; 4) COs had positive perceptions of the policy prohibiting the use of restraints on pregnant women in addition to concerns about policy implementation; 5) COs’ expressed varied perceptions of health services available to pregnant women.
COs recognized that pregnancy poses a unique challenge to maintaining professional boundaries in prison
COs recognized that pregnant women in prison have different needs (e.g. healthcare, physical, and emotional) from the general prison population. A commonly expressed view was that the isolation from social support, lack of physical comforts, and separation from their infants after giving birth were all unique and especially difficult conditions for women in prison. For example, one officer said, “I think it’s tough…they don’t really have a lot of support systems like you would on the outside.”
COs expressed empathy for pregnant women in prison, and most described a “natural” desire to offer them support. Exemplifying this feeling was one CO who said “I believe it is natural to feel empathy for someone who just gave birth to be separated from their child.” These feelings occurred throughout the pregnancy—were heightened during labor and delivery—and often blurred personal and professional boundaries. One officer said, “I mean it’s awkward because as one human to another … there’s a natural want to comfort somebody.” Another female officer remarked, “you really have to try to start to separate your emotions...which is hard for us, especially as women, and if we’re mothers and wives...well that could be your child or that could be you.”
All of the COs who participated in the interviews stressed the need to maintain professional boundaries with women in prison—a boundary that also applied to pregnant women. COs explained that providing emotional and physical support to pregnant women crossed professional boundaries and led to conflict with their primary job task of maintaining safety and security. This tension put them in an “awkward” and “unfair” position, especially in the setting of the delivery room, as they worked to maintain professional distance. One officer said, “There’s a natural barrier for me, where I can’t empathize with the offenders past a certain point, past a point that for me feels like a breach of professionalism.” Another CO stated, “Anybody with any compassion wants to do something for her ‘Can I get you anything? Can I do anything?’, but in our job capacity we, I, shouldn’t be doing anything.”
COs expressed that, in part to maintain professional boundaries, they did not treat pregnant women differently in day-to-day interactions other than straightforward accommodations to women’s physical needs. Interviewees commonly expressed statements such as, “I don’t generally treat [pregnant women] any differently than I would any other offender,” and “I don’t say it really differs, I mean, of course you have to accommodate their physical needs.”
COs perceived the prison doula program as benefitting pregnant women, infants, and their own work
The challenges of maintaining professional boundaries with pregnant women were mitigated by MCH programs and policies, and COs expressed appreciation for these programs and policies at the prison, particularly the prison doula program. COs perceived that doulas provided necessary physical, emotional, and moral support to pregnant women who experienced labor and delivery without family or friends. COs with longer tenures reflected on the experience of attending births at the hospital prior to implementation of the prison doula program in 2010; they described feeling pulled between providing emotional support and their job duties of maintaining security at the hospital. Two COs expressed the common sentiment that doulas filled this gap in services: “I think it’s less stressful for staff when [the doulas are] up there because it gives the offender somebody to have for support so that offender isn’t trying to get that support from staff,” and “I cannot be emotionally involved with the offender, so it’s good that [the doulas] are doing it.”
Doulas mitigated professional boundary conflicts by supporting pregnant women in ways that were outside of COs’ job responsibilities so that COs were better able to focus on their security duties. One CO explained, “it takes focus off of how comfortable is the offender, what can I do...it puts my focus back on my security.” COs perceived the doulas made pregnant women feel more supported and comfortable, which led to less volatile situations. As one CO explained, “We have a happier, better cared for offender, that makes our job easier, across the board for the most part.”
COs generally had positive perceptions of the prison doula program and identified benefits to the women, their infants, and the COs themselves. Multiple COs endorsed the program with statements such as “I would say it’s one of the state programs that’s worth holding onto when it comes to pregnant offenders.” COs perceived that the prison doula program benefited both pregnant women and infants by giving them a healthy start to life. One CO explained they believed infants benefited by explaining “If mom’s healthy and happy, then baby’s probably healthy and happy.” Multiple COs also described the prison doula program as a proactive program that not only benefited women and infants, but also benefited the prison in the long run. One CO said, “I think it prevents a lot of problems for the facility because it provides on the front end, it’s proactive versus reactive for the offenders … in the long run it’s a good thing.”
Lack of training about the prison doula program made COs’ jobs more difficult
While COs had positive perceptions of the prison doula program, they also expressed that a lack of training on the program added to their job demands and stress. COs stated that they had no knowledge of, or input into, the prison doula program when it began at the prison in 2010. Most COs expressed surprise or confusion regarding their first interactions with doulas, such as “I say initially no [I did not receive training], I kinda showed up and ‘who is that’? Is she supposed to be here? You know, she’s not in scrubs, what’s going on?’”
In the absence of formal training, most COs explained that they learned about the prison doula program “on the job.” One CO explained that they learned about the program through another more experienced CO: “luckily the officer that went up with me, she knew, and then she explained it to me.” Other COs reported being left on their own to understand both the role of the doula and their role as a CO in relation to the doula, “I’ve just learned through experience and trying to use my best judgement.”
This lack of training added awkwardness, uncertainty, and stress at the hospital. COs were concerned about what the doulas were and were not allowed to do; as one CO explained:
With new staff, if they're not exactly sure what [the doula’s] role is, then you know their mind is more security based, you know from the get-go, so they’re, you know, 'what’s she doing?' now they're trying to watch her too.
During the interviews, COs commonly requested formal training and information on the prison doula program, specifically the role and activities of the doula at the hospital. COs reported uncertainty on the specific items doulas were allowed to bring in (e.g., essential oils), the protocol for doulas’ taking and sharing pictures, doulas’ use of cell phones with the pregnant women, and physical touch with the pregnant women. The statement below from one CO echoed the sentiment of most of the COs interviewed:
I think maybe it would be awesome if staff, and maybe I'm out of turn here and maybe it has been done, but if staff could have a class on exactly what the doulas do, and what they're allowed to do, so that every time a new staff goes up with an officer, or with an offender, and the doula comes in they're not wondering, and they're not like 'you can't do that’.
COs had positive perceptions of the policy prohibiting the use of restraints on pregnant women, in addition to concerns about policy implementation
Generally, COs expressed that policies that prohibited the use of restraints on pregnant women met women’s unique physical needs and did not interfere with COs’ role in maintaining security. One CO described how the policy reduced concerns about restraints causing medical issues for pregnant women:
I think it's helped a lot. Because I think it's alleviated a lot of stress for officers...just the peace of mind I guess, you don't want anybody falling or getting hurt or there being an emergency situation...but you just kind of have that peace of mind that they're not restrained so it's not on me.
Another CO supported the policy because they felt discomfort restraining women in the hospital who were not deemed a security threat. They explained:
It makes it easier because it, nobody, I mean, you think I'm comfortable you know cuffing a pregnant woman?....We're being viewed as these brutal people you know and the woman just [gave] birth and so no, it's good for us. I think the changes are great.
However, uncertainty around consistent and universal enforcement of the policy regarding not restraining pregnant women created confusion and stress for some officers. Some COs, especially those who did not typically interact with pregnant women in their job role, suggested that changes to the policy over the years were not communicated in a systematic way to all COs. One CO expressed frustration with the communication of policy changes: “You have to stay current on how are we doing it now?” and another said the policy itself was “too confusing.” Additionally, COs reported there were not systems in place at the prison to communicate which women were pregnant, which could lead to unintentionally restraining a pregnant woman, especially early in her pregnancy. One CO expressed fear of discipline in these situations, “You handcuff a pregnant offender, you’re going to be investigated” and explained that the fear of discipline caused stress. While most COs expressed strong support for the practice of not restraining pregnant women, a lack of clear communication and training about policy changes and uncertainty about exceptions and special circumstances led to negative perceptions and stress for some COs.
COs’ expressed varied perceptions of the health services available to pregnant women
Most of the COs agreed that the health care pregnant women received at the prison was high quality and comparable or better than the care that women would have received in the community. Some COs expressed beliefs that this population of vulnerable, medically underserved women would likely not have access to adequate care in the community. As one CO explained “I think a lot of ‘em receive more than they would on the outside.”
Several COs discussed their perception that the instability of many of the women’s lives prior to coming to prison, especially substance use, meant that the women often received very limited prenatal care in the community. This perception was reflected in statements such as “They absolutely get phenomenal health care, they absolutely have better health care here”, and
Probably without a doubt this is probably—for I don't know what percentage I can give you—the only care that they get if they go to a doctor at all, and probably the best care that a lot of them would ever receive.
On the extreme end of COs’ positive health services perceptions, three COs expressed a belief that some women intentionally came to prison to access prenatal care. COs phrased these comments in juxtaposition to their perception that vulnerable women may slip through cracks in the community’s prenatal care system. One CO stated:
I think, honestly, that they like being here, that they prefer being in [the prison] than being at home cause they get all the health care that is required for pregnant women...some of them told me that 'I just came here cause I got pregnant and I figured that was the only way that I could get medical attention that I needed was to come here.’
The perception of high-quality health care in prison was not uniformly shared. Some COs stated that the health care was of lower quality because of the extra coordination that off-site medical appointments involved. COs expressed this belief with statements such as “I think high quality is too strong of a phrase, I’m glad they receive care but I don’t think they get as much care as they would if they were free to come and go” and “I don’t think we have enough medical staff here.” Other COs described the care as “comparable” to what women received on the outside. Overall, COs held varied and complex perceptions of the health care pregnant women received in prison.