I. Introduction

In April 2026, the South Carolina Senate passed the Women’s Childbirth Alternatives, Resources, and Education (CARE) Act (S0385) by a 31-3 margin, allowing pregnant women convicted of non-violent offenses to defer incarceration until after childbirth and at least twelve weeks postpartum. As the outcome of a rare consensus, the bill drew support from both Republican advocacy group Pro-Life Greenville and the American Civil Liberties Union of South Carolina, reflecting a growing bipartisan that the carceral system is simply not equipped to handle pregnancy. [1] Weeks earlier, advocates in Alabama supported a similar case for the Women’s CARE Act on the basis of the same understanding that the state assumes responsibility for the conditions of pregnancy when they take custody of a pregnant individual, and most facilities across the state, and the nation at large, fail to meet that responsibility. [2]

These legislative developments reflect a systemic failure that has largely been overlooked by Congress, despite the rate of incarcerated women having increased at twice the rate of incarcerated men from 1978 to 2015. [3] It is imperative to direct attention to the specific, neglected impacts that incarceration can have on women’s health, including maternal health and pregnancy-related policies within corrections. The Bureau of Justice Statistics notes in their 2023 “Maternal Healthcare and Pregnancy Prevalence and Outcomes in Prisons” report that over 700 pregnancies ended in prison in 2023, with 91% resulting in live childbirths. [4] Each of these pregnancies occurred under state custody, and therefore under state responsibility, raising significant constitutional and statutory implications. 

Incarcerated women arrive in custody already having faced disproportionate rates of intimate partner violence (IPV), childhood trauma, and untreated mental health disorders. The corrections environment is not only woefully insufficient in treating these conditions, but further compounds them. Pregnant women are often shackled during labor despite laws that prohibit the practice, newborns are removed from their mothers within hours of delivery, and postpartum depression often goes unaddressed. [5] Mental health complaints are dismissed and symptoms are penalized, reflecting a broader pattern of neglect within correctional facilities. However, the legal framework around maternal care in custody remains inconsistent and underenforced, leaving loopholes that undermine the protections. No federal statute establishes minimum standards for perinatal or postpartum care in corrections, and the Eighth Amendment’s standard for the treatment of incarcerated individuals has proven insufficient in its application to maternal and reproductive health. 

II. Pre-Existing Trauma Among Incarcerated Women. 

Incarcerated women experience consistently high rates of pre-existing trauma, which are often worsened by the corrections environment, shaping their mental and physical health outcomes. Justice-involved women report significantly higher levels of Adverse Childhood Experiences (ACEs) than the general population. [6] More than 70% have experienced IPV, [7] often involving severe cases such as rape or weapon use, [8] which can contribute to later substance use and mental health crises. [9] Over 90% of incarcerated women have experienced childhood trauma, including physical and sexual abuse. [10] These compounded histories contribute to a significant existing mental health burden, with 66% to 68% of incarcerated women having a diagnosed mental health disorder and up to 32% meeting the threshold for serious psychological distress. [11] Compared to incarcerated men, incarcerated women also experience disproportionately high rates of chronic illness, mental health disorders, and co-occurring conditions. [12]

This baseline has substantial legal significance, as under Estelle v. Gamble (1976), [13] the Eighth Amendment prohibits deliberate indifference to the serious medical needs of incarcerated individuals. As the correctional system is acutely aware of the incarcerated population’s psychiatric and obstetric vulnerabilities but fails to act, this article will examine the questions to that standard arising in the contexts of perinatal and postpartum healthcare for incarcerated women.

III. Trauma-Inducing Factors During Childbirth and Postpartum

A. Labor and Delivery

For women who are pregnant or give birth while in custody, the harsh, hostile conditions of labor and delivery in correctional settings can trigger existing traumatic histories and further traumatizing experiences for incarcerated women—who are particularly susceptible to retraumatization. Traditionally, the practice of shackling pregnant incarcerated people is common and normalized, justified as a method to prevent escape, prevent self-harm, or ensure the “safety” of corrections staff and medical practitioners during medical appointments, including during labor and delivery. [14] However, shackling can cause physical injuries to incarcerated individuals, such as bruising, abrasions, fractures, infections, and nerve damage. [15] Restraint use can make incarcerated women susceptible to falling, injuring themselves and risking the wellbeing of their fetus. [16] Medical complications are also uniquely heightened for risk of blood clots, hemorrhage, hypertension, preterm birth, along with labor and delivery complications such as abdominal trauma. [17] Shackling practices also reinforce psychological trauma and re-traumatize people by stripping them of dignity during a process that is already extremely vulnerable and physically painful. [18] Further, research shows that shackling can sever the trust between patients and providers, as the practice may reinforce the negative biases toward incarcerated individuals that healthcare staff and security may hold. [19] As a consequence, those who experience discrimination or stigma due to their criminal status have a higher chance of poor health outcomes. [20] Racial factors have shown to further contribute to the issue of medical trust and bias. [21] Physically, providers also face challenges when caring for patients who are shackled as they interfere with exams, surgery, and privacy. [22] Correctional officers often decide whether a patient can be de-shackled, impacting providers’ professional autonomy and ability to provide dignified care to their patients. [23] Research suggests that shackling can affect the wellbeing of healthcare workers by causing moral distress and value incongruence, leading to provider burnout. [24]

In response to the many health consequences that restraints pose to pregnant women and their children, as well as their implications for medical procedures, anti-shackling laws have been implemented in many states. Despite the existence of these laws, there are variations in the timing of restraint permittance and according policy transparency. Loopholes exist through exceptions of “extraordinary circumstances” where correctional security officers can determine a need for restraint use on a pregnant resident. [25] For instance, Maine’s policy on mechanical restraint use for pregnant residents allows the facility Chief Administrative Officer or designee to make the determination for restraint use if the pregnant individual is “a substantial flight risk or there is another extraordinary medical or security circumstance.” [26] Reflecting policies in other states, the “extraordinary circumstances” clause allows for these protections to be overridden based on the correctional authority’s judgment alone, without independent review or defined criteria. A 2018 national survey by the Association of Women’s Health, Obstetric and Neonatal Nurses found these loopholes are used commonly across the country, as 82.9% of nurses report that shackling of perinatal and laboring patients still occurs “sometimes to all of the time.” [27] The issue is compounded by inconsistent knowledge and enforcement of legal protections, as only 7.4% of the nurses surveyed could identify applicable state perinatal anti-shackling laws. [28] This lack of training and information results in ongoing confusion surrounding patient rights, which risk violations to any established protections. 

B. Postpartum Mother-Infant Separation

Following childbirth, trauma is often worsened by the forced separation of mothers and their infants. In the vast majority of prisons and correctional facilities in states across the United States, newborns are removed from their mothers’ physical custody shortly after birth. Only eight states currently offer nursery programs that allow infants to remain with their mothers, and these programs are implemented sparsely throughout women’s facilities across these states. [29] This mother-infant separation disrupts primary caregiving relationships, particularly given that 55% of incarcerated mothers lived with their children prior to incarceration and were twice as likely as incarcerated fathers to serve as the primary caretaker. [30] Structural barriers further prevent bonding, as most facilities lack policies to allow and facilitate breastfeeding, limiting opportunities for the biological and emotional connection that can mitigate postpartum distress. [31] In many cases, long-term incarceration can also lead to the termination of parental rights in 27 states. [32] As a result, mothers lose access to their children not only through temporary separation, but as a devastating loss of legal parental custody.

C. Heightened Postpartum Mental Health Challenges

The vulnerabilities that incarcerated pregnant women face are further intensified during the postpartum period following labor and delivery. For women who are not incarcerated, the rates of postpartum depression are already significantly high, impacting 1 in 8 women. [33] For incarcerated pregnant women, the disproportionate rates of existing mental health and trauma backgrounds, compounded by the trauma-inducing factors during childbirth along with the realities of mother-child separation drastically increase the prevalence of postpartum depression. Approximately one-third of incarcerated women meet the clinical criteria for moderate to severe postpartum depression (PPD) after childbirth, reflecting the heightened emotional and psychological strain of childbirth in a carceral setting. [34] This distress is often compounded by co-occurring conditions, including substance use disorders, which affect around 69-72% of incarcerated women, [35] along with raised levels of traumatic brain injury (TBI) histories compared to incarcerated men, [36] both of which can exacerbate mental health challenges and complicate recovery after childbirth. [37]

D. Systemic Barriers and Lack of Adequate Treatment

Systemic failures within correctional healthcare further exacerbate these mental health challenges and traumatic experiences. Women report frequent, lengthy delays in accessing both gynecological and mental health services, interfering with the timely care that is necessary during critical periods such as pregnancy and postpartum recovery. [38] Due to a large caseload and short staffing within many facilities’ corrections mental health units, psychological treatment often prioritizes medication management over psychotherapy, [39] which is often insufficient to address trauma symptoms and disorders. [40] Moreover, incarcerated women’s physical and mental health complaints are frequently stereotyped and dismissed as “malingering.” [41] As a result, many health concerns are overlooked, causing delays in diagnosis and care that can worsen medical symptoms or even become life-threatening scenarios. As correctional officers are often present during medical appointments, a lack of confidentiality also presents as a barrier preventing women from speaking openly about sensitive issues such as postpartum trauma. [42] In many cases, mental health symptoms are met with punitive responses such as disciplinary segregation or solitary confinement, further exacerbating psychological distress rather than providing appropriate care. [43]

IV. Conclusion

The experiences of pregnant and postpartum women in custody reveal a substantial gap between constitutional protections and the realities of incarceration. The Eight Amendment’s prohibition of “deliberate indifference” to serious medical needs is eroded by the treatment of incarcerated pregnant women and mothers. Correctional systems consistently fail to care for the medical and psychological needs that are pivotal during the childbirth process, including the use of shackling during labor, the immediate separation of mothers and infants, and the neglect of postpartum health concerns.

These inhumane practices and concerns are widespread across the country due to the consequences of a legal framework that lacks federal standards and structured oversight on implementation. Existing anti-shackling laws are undermined by discretionary loopholes, and correctional agencies repeatedly prioritize security concerns over maternal wellbeing, despite few legitimate safety justifications. These issues are compounded by the insular nature of corrections operations, resulting in a lack of transparent public reporting on demographic statistics and particular cases of shackling justification or mental health neglect. For women who arrive in custody with histories of trauma and mental health challenges, these neglectful reproductive health practices perpetuate psychological harm that have lasting effects beyond the sentence of incarceration. Consequences also directly extend to children and families, disrupting the attachment and caregiving relationships that are particularly critical during pregnancy and following childbirth.

Recent legislative efforts such as the Women’s CARE Acts in South Carolina and Alabama demonstrate a growing recognition that correctional facilities are not currently capable of providing sufficient care for women during pregnancy and postpartum recovery. To address these growing concerns, however, state reforms need to expand into national standards in order to address the widespread issues across agencies. Reform efforts must center the medical and psychological needs of incarcerated women by implementing changes such as sentence deferrals for pregnant individuals, expanded prison nursery programs that support mother-infant bonding, and stronger standard of care regulations for reproductive and mental health care in corrections. The treatment of pregnant incarcerated women implicates more than the singular demographic that is directly impacted, as it raises the question about the state’s obligations to provide sufficient and trauma-informed care when they assume custody over an individual’s body and health. A correctional system that punishes motherhood through trauma, neglect, and separation fails incarcerated women, as well as the very constitutional principles that are foundational to the system’s existence.

[1] Anna Wilder, “Pregnant Women Facing Non-Violent Sentences Can Defer Incarceration Under SC Senate Bill.” Post and Courier, April 18, 2026, https://www.postandcourier.com/politics/sc-senate-pregnant-women-prison-defer/article_b738a78a-f69a-4f10-b479-b3ffb6556503.html.

[2] Makhayla DesRosiers, “Women’s CARE Act Would Support Incarcerated Pregnant People in Alabama.” Southern Poverty Law Center, February 3, 2026, https://www.splcenter.org/resources/hopewatch/prison-deferral-postpartum-pregnant-women/.

[3] Wendy Sawyer, “The Gender Divide: Tracking Women’s State Prison Growth.” Prison Policy Initiative, January 9, 2018, https://www.prisonpolicy.org/reports/women_overtime.html. 

[4] Laura M. Maruschak, “Maternal Healthcare and Pregnancy Prevalence and Outcomes in Prisons, 2023.” Bureau of Justice Statistics, April 2025, https://bjs.ojp.gov/document/mhppop23.pdf.

[5]  Lorie S. Goshin, et al., “Perinatal Nurses’ Experiences with and Knowledge of the Care of Incarcerated Women During Pregnancy and the Postpartum Period.” 48 Journal of Obstetric, Gynecologic, & Neonatal Nursing (2019), at 27-36, https://www.sciencedirect.com/science/article/pii/S0884217518303666?via%3Dihub; Lorie Smith Goshin and Mary Woods Byrne, “Converging Streams of Opportunity for Prison Nursery Programs in the United States.” 48 Journal of Offender Rehabilitation (2009), at 271-295, https://doi.org/10.1080/10509670902848972; Mariann A. Howland, et al., “Depressive Symptoms Among Pregnant and Postpartum Women in Prison.” 66 Journal of Midwifery & Women’s Health (2021), at 494-502, https://pubmed.ncbi.nlm.nih.gov/34260138/.

[6] Melissa A. Bowles, et al., “Family Influences on Female Offenders’ Substance Use: The Role of Adverse Childhood Events among Incarcerated Women.” 27 Journal of Family Violence (2012), at 681-686, https://doi.org/10.1007/s10896-012-9450-4.

[7] Dana D. DeHart, “Pathways to Prison: Impact of Victimization in the Lives of Incarcerated Women.” 14 Violence Against Women (2008), at 1362-1381, https://www.doi.org/10.1177/1077801208327018.

[8] Dana DeHart, et al., “Life History Models of Female Offending: The Roles of Serious Mental Illness and Trauma in Women’s Pathways to Jail.” 38 Psychology of Women Quarterly (2014), at 138-151, https://doi.org/10.1177/0361684313494357.

[9] The Women’s Justice Commission, “A Preliminary Assessment of Women in the Criminal Justice System.” Council on Criminal Justice, July 2024, https://counciloncj.org/womens-justice-a-preliminary-assessment-of-women-in-the-criminal-justice-system/#20.

[10] Bowles, et al., supra note 6.

[11] Jennifer Bronson and Marcus Berzofsky, “Indicators of Mental Health Problems Reported by Prisoners and Jail Inmates.” Bureau of Justice Statistics, June 2017, https://s3.documentcloud.org/documents/3872819/Indicators-of-Mental-Health-Problems-Reported-by.pdf.

[12] Chelsi Lamberton and Michael S. Vaughn, “Correctional Medical Care for Female Prisoners: Legal Issues Surrounding Inadequate Treatment of Chronic and/or Preexisting Health Conditions.” 102 The Prison Journal (2022), at 493-514, https://journals.sagepub.com/doi/epub/10.1177/00328855221109824.

[13] Estelle v. Gamble, 429 U.S. 97 (1976).

[14] Lawrence A. Haber, et al., “Shackling in the Hospital.” Journal of General Internal Medicine (2022), at 1258-1260, https://link.springer.com/article/10.1007/s11606-021-07222-5. 

[15] Ibid.

[16] Jennifer G. Clarke and Rachel E. Simon, “Shackling and Separation: Motherhood in Prison.” 15 AMA Journal of Ethics (2013), at 779-785, https://journalofethics.ama-assn.org/article/shackling-and-separation-motherhood-prison/2013-09.

[17] Kayla Tabari House, et al., “Shackling and Separation: Motherhood in Prison.” 23 AMA Journal of Ethics (2021), at 364-368, https://journalofethics.ama-assn.org/article/ending-restraint-incarcerated-individuals-giving-birth/2021-04.

[18] Veronica Brawley and Emma Kurnat-Thoma, “Use of Shackles on Incarcerated Pregnant Women.” 53 Journal of Obstetric, Gynecologic, & Neonatal Nursing (2024), at 79-91, https://www.jognn.org/article/S0884-2175(23)00247-2/fulltext#:~:text=Scopus%20(27)-,).,and%20Prevention%20(CDC%2C%202022.

[19] Lawrence A. Haber, et al., “Acute Care for Patients Who are Incarcerated: a Review.” 179 JAMA Intern Med (2019), at 1561-1567, https://pubmed.ncbi.nlm.nih.gov/31524937/.

[20] Benjamin A. Howell, et al., “The Stigma of Criminal Legal Involvement and Health: a Conceptual Framework.” 99 Journal of Urban Health (2022), at 92-101, https://pubmed.ncbi.nlm.nih.gov/35031942/.

[21] Ibid.

[22] Rachel E. Armstrong, et al., “Addressing Emergency Department Care for Patients Experiencing Incarceration: a Narrative Review.” 24 Western Journal of Emergency Medicine (2023), at 654-661,  https://pubmed.ncbi.nlm.nih.gov/37527377/.

[23] Barbara Lois Zust, et al., “Nurses’ Experiences Caring for Incarcerated Patients in a Perinatal Unit.” 34 Issues in Mental Health Nursing (2013), at 25-29, https://pubmed.ncbi.nlm.nih.gov/23301566/.

[24] “A Call to Stop Shackling Incarcerated Patients Seeking Health Care.” American Public Health Association, November 13, 2023, https://www.apha.org/policy-and-advocacy/public-health-policy-briefs/policy-database/2024/01/16/shackling-incarcerated-patients.

[25] Camille Kramer, et al., “Shackling and Pregnancy Care Policies in US Prisons and Jails.” 27 Maternal Child Health Journal (2022), at 186-196, https://pmc.ncbi.nlm.nih.gov/articles/PMC9660187/#:~:text=Data%20indicate%20that%20pregnancy%20policies,require%20a%20female%2Didentifying%20officer.

[26] Maine Department of Corrections, Use of Mechanical Restraints on a Pregnant Prisoner or Pregnant Resident, Policy No. 18.19.1 and 13.19.1 (October 5, 2016; rev. June 6, 2017), https://www.maine.gov/corrections/sites/maine.gov.corrections/files/inline-files/18.19.1%20and%2013.19.1%20USE%20OF%20MECHANICAL%20RESTRAINTS%20ON%20A%20PREGNANT%20PRISONER%20OR%20PREGNANT%20RESIDENT.pdf. 

[27] Goshin, et al., supra note 5.

[28] Ibid.

[29] Goshin and Byrne, supra note 5.

[30] Laura M. Maruschak and Jennifer Bronson, “Parents in Prison and Their Minor Children.” Bureau of Justice Statistics, March 2021, https://bjs.ojp.gov/content/pub/pdf/pptmcspi16st.pdf.

[31] Shela Akbar Ali Hirani and Natasha Taylor, “Barriers and Strategies to Support Breastfeeding Practices of Incarcerated Women in the Correctional Settings: a Scoping Review.” 16 Clinical Lactation (2025), https://connect.springerpub.com/content/sgrcl/16/3-4/126.

[32] Child Welfare Information Gateway, “Grounds for Involuntary Termination of Parental Rights” (2021), https://www.childwelfare.gov/resources/grounds-involuntary-termination-parental-rights/.

[33] “Symptoms of Depression Among Women.” Centers for Disease Control and Prevention, May 15, 2024, https://www.cdc.gov/reproductive-health/depression/index.html.

[34] Mariann A. Howland, et al., “Depressive Symptoms Among Pregnant and Postpartum Women in Prison.” 66 Journal of Midwifery & Women’s Health (2021), at 494-502, https://pubmed.ncbi.nlm.nih.gov/34260138/.

[35] Jennifer Bronson, et. al., “Drug Use, Dependence, and Abuse Among State Prisoners and Jail Inmates.” Bureau of Justice Statistics (June 2017; rev. August 10, 2020), https://bjs.ojp.gov/content/pub/pdf/dudaspji0709.pdf.

[36] Eric Durand, et al., “Traumatic Brain Injury Among Female Offenders in a Prison Population: Results of the FleuryTBI Study.” 7 Brain and Behavior (2016), https://doi.org/10.1002/brb3.535.

[37] Shawna L. Carroll Chapman and Li-Tzy Wu, “Postpartum Substance Use and Depressive Symptoms: a Review.” 53 Women & Health (2014), at 479-503, https://pmc.ncbi.nlm.nih.gov/articles/PMC3742364/; Hilary K. Brown, et al., “A Population-Based Cohort Study of Perinatal Mental Illness Following Traumatic Brian Injury.” 34 Epidemiology and Psychiatric Sciences (2025), https://pmc.ncbi.nlm.nih.gov/articles/PMC11955423/.

[38] Kate Walsh, “Inadequate Access: Reforming Reproductive Health Care Policies for Women Incarcerated in New York State Correctional Facilities.” Columbia Journal of Law & Social Problems (2024), https://jlsp.law.columbia.edu/wp-content/blogs.dir/213/files/2017/03/50-Walsh.pdf.

[39] Gina L. Fedock, et al., “‘You Have to Take Care of Your Own Mental Status’: Incarcerated Women Seeking Care Within and Beyond Mental Health Treatment.” 39 Affilia: Feminist Inquiry in Social Work (2023), https://doi.org/10.1177/08861099231196223.

[40] Institute for Quality and Efficiency in Health Care, “Post-traumatic stress disorder (PTSD): Learn More – Medication for post-traumatic stress disorder,” InformedHealth.org (2023), https://www.ncbi.nlm.nih.gov/books/NBK532841/.

[41] Lamberton and Vaughn, supra note 12.

[42] Walsh, supra note 37.

[43] Lamberton and Vaughn, supra note 12.