Denise Marshall looks at improving perinatal care and support for women in prison
Twenty years ago, the situation of women giving birth in custody came to public attention when Beverley Beech filmed a woman from Holloway prison, shackled in labour. Now, Birth Companions is launching a Birth Charter for perinatal women in prison in England and Wales1 and, once again, there is a focus on this group of women and babies.
In February, David Cameron called for an urgent rethink of their treatment in custody; a few weeks ago, in The Archers radio drama (BBC Radio 4), Helen Archer gave birth and is now a mother breastfeeding in prison and the closure of Holloway prison is imminent.
Let's go back to the end of 1995 when Annette, in prison for a stealing a handbag, wrote to Beverley Beech about the indignities that she was experiencing as a pregnant woman in prison. She asked if Beverley could be her birth partner. Beverley came to the hospital with a concealed camera, and, with Annette's permission, filmed part of her labour, highlighting the shocking practice of shackling women in labour. After the footage was shown on Channel 4, there was public outrage and the matter was discussed in Parliament.
For a short while, a spotlight was shone on one of the most marginalised groups of people in Britain, women in prison, resulting in change for women who were pregnant and giving birth in custody: they were no longer to be handcuffed, once they were in labour. Childbirth campaigner Sheila Kitzinger called together north London antenatal teachers and midwives to talk about what else could be done for the women in Holloway and, out of this meeting, Birth Companions was born.
There was a desire for change from the prison as well. The Prison Governor agreed that Birth Companions could start immediately, supporting women at birth at the Whittington hospital. I had just begun as an antenatal teacher in the prison. every Tuesday, the pregnant women would pile in, sometimes sitting on laps, there could be twenty women or more. Birth Companions volunteers came each week to meet women, offer birth support and do birth plans. It was very unlike other antenatal classes. As well as the usual hopes and fears about birth and becoming a parent, women worried about being unlocked in time to get to the hospital for birth and whether officers would be in the room with them when their baby was born. Would they get a place with their baby on the Mother and Baby Unit (MBU) or have to separate after the birth? Most women had other children at home and shared their sadness about being apart from them. Some women had only discovered they were pregnant once in custody, so were coming to terms with this, as well as the shock of being in prison. Women, who spoke no English, came with another non-pregnant prisoner who interpreted discussions about choices in labour and baby feeding. What was striking was how much some women wanted the information and support to give their baby the best start possible in this difficult situation. Also, how relieved women were to know they could have a birth companion with them, and would not be giving birth alone. Some women did have family but worried whether they would be called or arrive in time. The groups gave space for women to support each other and the strength of this peer support was sometimes quite incredible.
Over the years, Birth Companions continued to work with women in Holloway in a trauma-informed way, being woman-centred and providing a safe space in the harsh environment that prison can be. There was a Birth Companions antenatal group (after mine closed due to budget cuts), an early parenting group on the MBU, and a breastfeeding supporter who could work with women during pregnancy, early parenting and also with women who were separated from their baby and wished to express milk. Birth Companions also began to work with women after release in London, and in Bronzefield and Peterborough prisons. The birth companions I worked with, as well as the courage of some of the women in prison, inspired me.
One woman wrote, about the antenatal group: 'I felt a huge amount of support. I was able to share my experiences with the other girls and the birth companions without fear of judgement. I was never asked why I was here and for the two hours of the group I didn't feel I was in prison. It just felt like we were all mums looking forward to our new arrivals with no stress.'
This woman did not get a place on the MBU but was supported to express milk for her baby: 'They gave me the right amount of advice and support which encouraged me to give it a try, which I loved. I didn't have my son with me unfortunately but they taught me to express so my son could still benefit, which is the best thing I ever did.'
Women in prison continue to be a vulnerable and small minority (fewer than 5%) in a system designed for men. Most women in prison have experienced emotional, physical or sexual abuse (53%, compared with 27% of men) and 31% have spent time in care, based on Ministry of Justice 2013 figures. Most women have substance or alcohol misuse problems before coming into custody and physical and mental health levels are worse than any other recorded group.2 Statistics are not collected for pregnant women but it is estimated that over 600 receive antenatal care and 100 give birth in custody each year. Many more women have recently been released, are on bail, are electronically tagged (Home Detention Curfew), serving community sentences or have a partner in prison, and are affected by this during the perinatal period.
Now, 20 years later, Birth Companions has launched the Birth Charter and we hope again, that something will change. The Birth Charter is based on our work with approximately 1,500 women (mainly in Holloway) at different stages of pregnancy, birth and early parenting and what they told us about their experiences. It was a huge piece of work but we wanted the Birth Charter to be thorough and to reference relevant research. We also had input from the Royal College of Midwives and Unicef UK Baby Friendly Initiative. In theory, women in prison are entitled to the same standard of maternity care and choice as women in the community but, for reasons that can be complex, this is not always the case. The Birth Charter sets out fifteen recommendations that would ensure equivalence of care and could form the basis of a Prison Service Instruction (PSI) for Perinatal Women in prison. An existing PSI covers what happens for mothers and babies who go on to prison Mother and Baby Units but not what happens for pregnant women or for mothers and babies who do not get a place together on a MBU and are separated (approximately half of women do not apply or are refused a place with their baby in prison).
Since Annette was shackled in labour, some things have changed for the better but others have not and experiences vary enormously. Some very dedicated prison staff make a real difference to the women they work with. For some women, coming to prison provides respite, away from an abusive partner or from living on the streets. Getting a place on a prison MBU can enable women to make a new start with their baby. There are some real success stories, a testament to what can happen when support is there at this crucial time. Many women stay in contact with us and are quoted in the Birth Charter. A woman we supported at her birth told us: 'I was fortunate to go back to the Mother and Baby Unit at Holloway and three weeks later to a mother and baby rehab. Thanks to support I completely turned my life around and have been clean six years this year.'
Other women felt their baby was also being punished while they were pregnant in prison because of experiencing unnecessary stress, particularly around their MBU place. 'The not knowing [about whether or not I had a place on the MBU] was making me ill, was making me anxious, just making me so frustrated ... I came to prison in May and I was told it's a 2/3 month process. I sat the Board [and got my place at a MBU in another prison] and I still didn't go.'
The Birth Charter addresses ways in which stress for pregnant women in prison can be reduced and calls for officers to have clear guidance and appropriate training. There are too many instances of women being handcuffed during scans, officers staying in the room (uninvited) with women during medical consultations, active labour and when women are having skin to skin or breastfeeding after the birth. It is difficult for women to be assertive while in custody and, although medical staff do ask officers to step outside or remove restraints in these situations, not all staff are aware of the woman's rights around this.
The Birth Charter includes many examples of good practice in prisons, which are sometimes lost when staff change or budgets are cut. From 1998, women in Holloway received excellent maternity care from midwives from the Whittington hospital who ran clinics in the prison three times a week. This minimised the need for women to go out to hospital during pregnancy, handcuffed and accompanied by uniformed officers on their way to clinics, and women felt safer and less stressed. For years there was a mobile phone in Holloway that women could use to speak to a midwife on labour ward for advice. An officer would hand the phone to a woman in her cell, giving her access to a midwife, as she would have in the community, and then speak to the midwife to confirm transfer to hospital, if that had been the advice. This system no longer exists and so pregnant women in prison discuss bleeding, headaches, waters breaking and early contractions with officers and in-house nursing staff, instead of a midwife, to negotiate going out to hospital (despite the Nursing and midwifery Order (2001) Article 453)3.
Things in Holloway prison were far from ideal but a huge amount was learned there and all the expertise from staff, external agencies, therapists and others should not be lost. Birth Companions is hoping to work with the Prison Service and individual prisons, using the Birth Charter as a basis for improving care for this group of women and babies. We are also developing modules with the Royal College of Midwives on theirvirtual learning platform. So, as well as being the end of an era, the closure of Holloway could also mark be the beginning of a more consistent and enlightened approach for women and babies affected by the Criminal Justice system.
Denise Marshall, Group Co-ordinator for Birth Companions
2. Prison Reform Trust (2014) Bromley Briefings 2014, www.thebromleytrust.org.uk/files/bromleybriefingsautumn2014.pdf
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