The Double-Edged Baton of Incarcerated Pregnancy Moral Harms and the Role of Correctional Officers During Labor and Delivery

Abstract

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Introduction

Some jurisdictions in the United States permit correctional officers to remain in the hospital room during the labor and delivery of an incarcerated person, usually justified as a measure of safety and security.^[1]  This practice exposes the correctional officer to secondary traumatic stress and causes moral injury, both of which increase the likelihood of PTSD and suicide. Correctional staff have extremely high rates of job turnover, stress, burnout, and PTSD, but moral injury, a large contributor to PTSD, is relatively understudied in this population. Further, incarcerated pregnancy research does not often focus on carceral staff, but doing so would promote better practices and health outcomes for both staff and incarcerated people. For incarcerated people, labor and delivery are highly traumatizing and there is often little to no peripartum emotional support available. Correctional officers remaining for labor and delivery further traumatize the laboring person by invading their privacy and inconsistently violating boundaries due to a lack of training and clear guidelines.

Emotional Landscape of Prison

Somewhat akin to healthcare settings, prisons are very intimate yet detached environments. Incarcerated populations spend months to years in the same space surrounded by many of the same people. Carceral staff similarly spend much more time in close quarters with the people they work with and supervise than is typical in other professions. This prolonged proximity often develops into relationships of mutual recognition or even fondness between staff and incarcerated people.

However, these relationships are at odds with prison policy and culture. Detachment is strongly encouraged, both formally through policy and trainings, and informally through interactions with peers.^[2] Staff-incarcerated person relationships often result in boundary violations, which are, “actions that blur, minimize, or disrupt the professional relationship between correctional staff members and prisoners,” ranging from minor infractions, such as offering a gift (often quid pro quo), to major harms such as sexual or economic favors.^[3] Boundary violations build upon previous infractions over time by introducing higher stakes and more emotional involvement, like blackmail, which undermines the professional obligations of staff.^[4] Furthermore, the inherent power imbalance of these relationships obscures consent, allowing coercion, manipulation, and confusion. Additionally, institutional guidelines and trainings don’t always adequately prevent relationships and boundary violations due to a lack of consensus and cohesion of values across sectors and institutions.^[5]

The competing intimacy of the prison and the encouraged detachment between staff and incarcerated people create gray areas among expectations and boundaries. Lack of cohesive training also contributes to moral tension and distress among carceral staff when they are unsure of how to balance competing feelings and obligations.

Moral Distress and Injury

Structural consequences of the prison-industrial complex, such as mass incarceration, low staff salary and support, and minimal training contribute to the incredibly high stress environment of prison. Carceral staff burnout and turnover rates remain very high, while incarceration rates are increasing, after decreasing from 2010 to 2021, leaving remaining staff overworked and overstressed.^[6] This, in turn, worsens the treatment of incarcerated people and staff and increases the likelihood of experiencing a traumatic event, which proportionally increases the risk of PTSD.^[7] Because of these factors, carceral staff, compared to other occupational groups, have extremely high rates of depression, anxiety, PTSD, and suicide.^[8]

One of the strongest predictors of burnout, PTSD, and suicide is experiencing moral injury alongside a traumatic event, even when accounting for age, sex, depression, anxiety, stress, and childhood adversity.^[9] Moral injury is the psychological, spiritual, and behavioral distress experienced when perpetrating or witnessing events that transgress deeply held moral beliefs.^[10] For correctional officers, moral injury occurs when professional policy and obligations come into conflict with moral or emotional obligations.^[11]

Moral injury is heightened due to the competing intimacy and detachment of the prison. Specifically, the unique expectations of prison, such as maintaining security, conflict with the actual experiences of correctional officers, such as the relationships of proximity they develop. Correctional staff might have professional obligations to the prison, which override the moral or emotional obligations they feel toward incarcerated people, giving rise to moral distress.

Incarcerated Pregnancy

Incarcerated pregnancy practices are disparate and dependent on individual state and institution policies, despite an estimated four percent of incoming incarcerated people being pregnant.^[12] Furthermore, the modern prison was designed to accommodate men, and often fails to address the unique health needs of women.^[13] It is only recently that a majority of states have banned the use of shackles on pregnant people during labor and delivery, despite no record of attempted escape or violence during labor. The federal government also bans the practice for those in federal prisons.^[14] Eight states still have no policy against shackling, either during transport or during labor and delivery. However, even though anti-shackling policy exists, it isn’t consistently adhered to and often depends on the discretion of individual correctional officers and healthcare professionals.^[15] This means that shackles are still used and putting pregnant incarcerated people at risk of severe birth complications due to reduced mobility and fall damage.

Another problem with incarcerated pregnancy is the separation of babies and parents. Generally, in the US, babies will be separated from their incarcerated parent within hours to days. Separation of child from parent after birth greatly increases the health risks posed to both, including worsened postpartum depression for parents.^[16] Children are either put under care of contactable family members, or if there are none, sent into the foster care system.^[17] Eight states have prison nurseries where parents can stay with their children for 12-36 months, but these are generally people incarcerated for short-terms, and for non-violent offenses.^[18]

Furthermore, incarcerated pregnant people are often ill-informed of their birthing plan, such as when they will give birth if induced and which hospital they will go to. ^[19] Typically, policies allow pregnant incarcerated people to choose their own birth coach, who can be a spouse, female relative, or female friend (but unmarried partners such as boyfriends, even if they are the biological parent of the child, are often not allowed). However, birth coaches frequently do not attend the birth because they are not contacted in advance, even when labor is induced. Other times, birth coaches are not contacted at all.^[20] This means that many incarcerated people are forced to give birth with little to no emotional support.

Overall, incarcerated pregnancy and birth are highly problematic. Inadequate adherence to policy and inadequate policy dehumanize and traumatize birthing people by shackling them, invading their privacy, and offering little to no emotional support when birthing and being separated from their child. Because of this, incarcerated labor and delivery is a disproportionately traumatizing experience compared to non-incarcerated labor and delivery.

Correctional Officer Presence

Correctional staff often remain in the labor and delivery room in the interest of security. These staff members are frequently male and poorly trained in basic women’s health, although some states require attending officers to be female-identifying.^[21] Sometimes the birthing person can choose the correctional officer. However, lack of scheduling and communication can prevent chosen officers from being present.^[22] Even though it is common practice for correctional staff to remain, general prison policy fails to define how staff should engage during labor and delivery, leaving staff to use their discretion. This leads to inconsistent treatment and reactions from staff.

Correctional officers report feeling ill-equipped to handle the stresses of incarcerated birth.^[23] Lack of training on what to expect during pregnancy and birth creates uncomfortable exchanges during labor and delivery, such as some officers reacting with disgust or apathy towards uncontrollable biological processes.^[24] Other officers are more avoidant, choosing to disengage, remain silent, or even watch the tv in the delivery room. Laboring people described both types of accompanying correctional officers as increasing their discomfort and distress.^[25]

Another type of officer is the ‘maternal’ figure.^[26] These are usually more senior female officers who have more experience with birth. They are much more empathetic and likely to offer emotional support to the birthing person, such as holding their hand, which is against most policies. In the absence of any other support, laboring individuals found these interactions comforting and helpful and preferred the presence of these officers to being alone.^[27] However, these interactions are boundary violations because they breach the professional role of correctional staff. When this emotional connection is made, it can lead to future distress and confusion for incarcerated individuals when staff inevitably transgress the ’caring’ role and revert to ‘keeper’ or ‘punisher’.^[28]

Many correctional officers want to act empathetically, but most do not feel comfortable breaking policy to offer support to laboring people.^[29] Correctional officers who witness the firsthand trauma of labor the incarcerated pregnant people experience are at risk of experiencing secondary traumatic stress, which increases their risk of PTSD.^[30] They are further at risk of moral injury because of their conflicting moral appraisals of the situation. For example, they might believe that because the laboring individual is incarcerated, they lose certain rights such as remaining with their child, and that prison policy must be followed. At the same time, correctional officers might also believe they have a moral obligation to reduce the explicit suffering of the laboring individual, for example by offering emotional support or caring for the baby when the parent becomes too tired. This tension between obligations of detachment and intimacy is the foundation for moral injury which correctional officers describe feeling during labor and delivery.^[31]

Furthermore, labor and delivery are much more intimate, vulnerable, and traumatizing than general prison life. Correctional staff are not equipped with the proper training (in trauma-informed care, birth, and postpartum care, for example) to prevent further harm against themselves and laboring individuals. Although this is outside the scope of the present argument, it is worth noting that labor and delivery can be so intimate that it inherently compromises the professional relationship, as correctional staff are not trained health professionals and have much more prolonged contact with laboring people than any provider would.

In the interest of incarcerated people, correctional officer presence during labor and delivery causes harm by invading privacy and creating inconsistent interactions and expectations between staff and incarcerated people. In the interest of correctional staff, being present during labor and delivery compromises the professional relationship and contributes to moral injury, which increases burnout, PTSD, and suicide.

Recommendations

1. The first change should be the complete removal of correctional staff from labor and delivery for the reasons outlined above. This is highly feasible and poses minimal risk; some states already ban officers from labor and delivery rooms.^[32] However, better guardrails and accountability measures must be in place to ensure this practice is followed. Should officers be requested by the laboring person or medical staff, officers must have better training and experience with labor and delivery to appropriately accompany.


2. The most appropriate support people for laboring incarcerated individuals are their chosen birth coaches and visitors. Although some believe allowing coaches and visitors increases the risk of escape or collusion, there have been no recorded attempts. Furthermore, most pregnant incarcerated people are incarcerated for non-violent crimes and pose low security and flight risks.^[33] To quell concerns, prisons might vet birth coaches. Better communication and planning must occur so that birth coaches can attend the labor and delivery.


3. Another option is doula support programs. Doulas are trained to provide emotional, informational, and advocacy support for pregnant and laboring individuals. Many doula support programs for prisons and jails exist and both laboring people and doulas find them feasible and highly satisfactory.^[34] Doulas can provide support for pregnant incarcerated people without the ethical concerns of moral injury and boundary violation associated with correctional officers. Some programs train currently incarcerated people to become doulas upon release, which might be even more beneficial for pregnant incarcerated people as they share experiences which are less understood by non-incarcerated doulas.^[35] The success of a doula program requires correctional officer involvement and training covering what doulas are allowed to do.^[36]


4. If doulas are not feasible, community members and organizations such as chaplains, social workers, counselors, or non-profits should be involved as additional support for laboring people. Like doulas, these community members can provide unconflicted support that correctional officers cannot. Furthermore, social workers might be able to reduce the anxieties of incarcerated parents and their families, and help make plans for ensuring the care, protection, and eventual reunion with their children.


5. A much more involved option is a prison nursery. These are units where parents are allowed to stay with their children for 12-36 months after birth. By not immediately separating parents from their children, some of the trauma associated with incarcerated pregnancy is reduced, which also reduces the secondary traumatic stress experienced by correctional staff. Prison nurseries also reduce recidivism rates and promote better health outcomes for parents and children.^[37] However, this option isn’t widely accessible because it requires significant funding and planning, and getting a spot isn’t guaranteed.


6. With the implementation of the other recommendations, better psychological resources must be allocated to incarcerated pregnant people and correctional officers, such as information sessions, counseling, and wellness services. Prison culture promotes emotional detachment from oneself and others, both in the interest of professionalism and by various stigmatizing social factors. This culture must be changed to promote trust and mental health among staff and incarcerated people.


7. Finally, pregnant people should be incarcerated only as a last resort. Most pregnant people are incarcerated for non-violent drug or property-related offenses.^[38] Given the negative health outcomes of being incarcerated and the increased strain on an already overpopulated system, prisons are unable to ensure a safe environment for pregnancy.^[39] Instead, convicted pregnant people should have access to and benefit from more restorative justice efforts and resources, such as rehabilitation programs.

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[1] Common prison policies differ. Some policies permit correctional staff to remain in the labor and delivery room while others prohibit them from entering, unless at the request of medical staff. Other institutions have no policy on officer attendance. Some states, such as New York and Maine, have legislation banning officer presence. Officer presence during labor and delivery is largely at the discretion of individual states, institutions, and medical and carceral staff.

[2] Dial, K. C., & Worley, R. M. (2007). Crossing the line: A quantitative analysis of inmate boundary violators in a southern prison system. American Journal of Criminal Justice, 33(1), 69–84. https://doi.org/10.1007/s12103-007-9015-x

[3] Marquart, J. W., Barnhill, M. B., & Balshaw-Biddle, K. (2001). Fatal attraction: An analysis of employee boundary violations in a southern prison system, 1995–1998. Justice Quarterly, 18(4), 877–910. https://doi.org/10.1080/07418820100095121; Worley, R. M., Tewksbury, R., & Frantzen, D. (2010). Preventing fatal attractions: lessons learned from inmate boundary violators in a southern penitentiary system. Criminal Justice Studies, 23(4), 347–360. https://www.ojp.gov/ncjrs/virtual-library/abstracts/preventing-fatal-attractions-lessons-learned-inmate-boundary

[4] Worley, R., Marquart, J. W., & Mullings, J. L. (2003). Prison guard predators: An analysis of inmates who established inappropriate relationships with prison staff, 1995-1998. Deviant Behavior, 24(2), 175-194.

[5] Farley, H., & Hopkins, S. (2018). Moving forward together: Supporting educators to support incarcerated students in Australian prison-based higher education. Advancing Corrections: Journal of the International Corrections and Prisons Association, 6, 145–152.

[6] Carson, E. A. (2021). Prisoners in 2021 – Statistical Tables. Bureau of Justice Statistics. https://bjs.ojp.gov/media/68246/download

[7] Zhang, Z., Li, Y., Wang, S., Wang, J., Huang, Y., Wang, X., Guo, H., & Zhou, J. (2024). Exploring the impact of workplace violence on the mental health of Chinese correctional officers: A JD-R model approach. Psychology Research and Behavior Management, 17, 2865–2874. https://doi.org/10.2147/PRBM.S468370   

[8] Schultz, W. J., & Ricciardeli, R. (2024). Correctional officers and the ongoing health implications of prison work. Health & justice, 13(1), 4. https://doi.org/10.1186/s40352-024-00308-2

[9] Easterbrook, B., Plouffe, R. A., Houle, S. A., Liu, A., McKinnon, M. C., Ashbaugh, A. R., Mota, N., Afifi, T. O., Enns, M. W., Richardson, J. D., & Nazarov, A. (2023). Moral injury associated with increased odds of past‐year mental health disorders: A Canadian Armed Forces examination. European Journal of Psychotraumatology, 14(1), Article 2192622. 10.1080/20008066.2023.2192622; D'Alessandro-Lowe, A. M., Scott, A. M., Patel, H., Easterbrook, B., Ritchie, K., Brown, A., Pichtikova, M., Karram, M., Sullo, E., Mirabelli, J., Schielke, H., Malain, A., O'Connor, C., Remers, S., Lanius, R., McCabe, R. E., & McKinnon, M. C. (2025). Exploring the association between moral injury and posttraumatic stress symptoms among Canadian public safety personnel. Journal of traumatic stress, 38(2), 272–283. https://doi.org/10.1002/jts.23122

[10] Litz, B. T., Stein, N., Delaney, E., Lebowitz, L., Nash, W. P., Silva, C., & Maguen, S. (2009). Moral injury and moral repair in war veterans: A preliminary model and intervention strategy. Clinical Psychology Review, 29(8), 695–706. 10.1016/j.cpr.2009.07.003

[11] Ricciardelli, R., Easterbrook, B., & Turner, J. (2024). The continuum of moral harms: Correctional officers’ perspectives of prison and the influence on their wellness. Journal of Police and Criminal Psychology, 39(4), 845–856. https://doi.org/10.1007/s11896-024-09659-w

[12] Sufrin, C., Beal, L., Clarke, J., Jones, R., & Mosher, W. D. (2019). Pregnancy outcomes in US prisons, 2016–2017. American journal of public health, 109(5), 799-805.

[13] Wilson, S. H., Marsh, L. N., Zielinski, M., Corbett, A., Siegler, A., & Shlafer, R. (2022). Enhanced Perinatal Programs for People in Prisons: A Summary of Six States' Programs. Journal of criminal justice, 83, 101965. 10.1016/j.jcrimjus.2022.101965

[14] Pregnancy Anti-Shackling State Laws. Advocacy and Research on Reproductive Wellness of Incarcerated People. (2025, October); S.756 - 115th Congress (2017-2018): First Step Act of 2018. (2018). https://www.congress.gov/bill/115th-congress/senate-bill/756

[15] Sufrin, et al., 2019.

[16] Chambers, A. N. (2009). Impact of forced separation policy on incarcerated postpartum mothers. Policy, Politics, & Nursing Practice, 10(3), 204-211.

[17] Carlson J (2018). Prison nurseries: A way to reduce recidivism. The Prison Journal, 98(6), 760–775. https://doi.org/10.1177/0032885518812694   

[18] Sufrin, et al., 2019.

[19] Fritz, S., & Whiteacre, K.W. (2016). Prison nurseries: Experiences of incarcerated women during pregnancy. Journal of Offender Rehabilitation, 55, 1 - 20.

[20] Sufrin, et al., 2019.

[21] An Act To Prevent the Shackling of Pregnant Prisoners and Pregnant Juveniles, (2015). https://legislature.maine.gov/legis/bills/bills_127th/chapters/PUBLIC315.asp

[22] Abbott, L. (2018). Escorting pregnant prisoners—the experiences of women and staff: ‘Quite a lot of us like doing it, because you get to see a baby, or you get to see a birth’. Prison Service Journal no. 145, (241), 20-26.

[23] Abbott, 2018.

[24] Suarez A. (2021). "I Wish I Could Hold Your Hand": Inconsistent Interactions Between Pregnant Women and Prison Officers. Journal of correctional health care: the official journal of the National Commission on Correctional Health Care, 27(1), 23–29. https://doi.org/10.1089/jchc.19.06.0048

[25] Suarez, 2021.

[26] Abbott, 2018.

[27] Abbott, 2018.

[28] Dirks, D. (2004). Sexual Revictimization and Retraumatization of Women in Prison. Women's Studies Quarterly.

[29] Suarez, 2021.

[30] Brend, D. M., Herttalampi, M., & Sprang, G. (2025). Correctional officer experiences of moral distress, trauma-informed organizational practices, and structural stigma. Traumatology, 31(4), 634–644. https://doi.org/10.1037/trm0000579

[31]Suarez, 2021.

[32] An Act To Prevent the Shackling of Pregnant Prisoners and Pregnant Juveniles (2015). https://legislature.maine.gov/legis/bills/bills_127th/chapters/PUBLIC315.asp

[33] Grassley, J. S., Ward, M., & Shelton, K. (2019). Partnership between a health system and a correctional center to normalize birth for incarcerated women. Nursing for Women's Health, 23(5), 433-439.

[34] Shlafer, R.J., Hellerstedt, W.L., Secor-Turner, M., Gerrity, E. and Baker, R. (2015), Doulas’ Perspectives about Providing Support to Incarcerated Women: A Feasibility Study. Public Health Nurs, 32: 316-326. 10.1111/phn.12137 ; Schroeder, C. and Bell, J. (2005), Doula Birth Support for Incarcerated Pregnant Women. Public Health Nursing, 22: 53-58. 10.1111/j.0737-1209.2005.22108.x

[35] Doula training program. Federal Bureau of Prisons. (2024, January 29). https://www.bop.gov/news/20240129-doula-training.jsp

[36] Pendleton, V., Saunders, J. B., & Shlafer, R. (2020). Corrections officers’ knowledge and perspectives of maternal and child health policies and programs for pregnant women in prison. Health & Justice, 8(1). https://doi.org/10.1186/s40352-019-0102-0

[37] Chambers, 2009.

[38] Zielinski, M. J., Smith, M. S., & Stahman, A. (2024). Custodial and perinatal care patterns of women who received prenatal care while incarcerated in the Arkansas state prison system, 2014-2019. Health & justice, 12(1), 16. https://doi.org/10.1186/s40352-024-00268-7

[39] Hutchinson-Colas, J., & AlShowaikh, K. (2022). Pregnant Behind Bars. American journal of public health, 112(1), 14–16. https://doi.org/10.2105/AJPH.2021.306580