COVID-19 and pregnancy care for incarcerated women.

The impact of Coronavirus Disease 19 on vulnerable populations is far beyond one's imagination. For pregnant incarcerated women, a population that already has barriers to healthcare, COVID-19 adds another layer. Estimates suggest that there are over 704,000 female prisoners around the world, which is about 9% of the total prison population worldwide. A significant percentage of these women are of childbearing age and pregnant at the time of incarceration [1]. These women are vulnerable people in society because of socioeconomically marginalized backgrounds, substance misuse, victimization, medical and mental health disorders, as well as the increased risk of pregnancy and birth complications [2]. Attempts have been made by the international community to create guidelines to address care for these women, especially around prenatal and mental health care. More acutely, the community must now address these issues in a global pandemic.

Prior to the pandemic, many pregnant incarcerated women received insufficient antenatal care [3], often due to significantly greater challenges in accessing transportation to attend prenatal appointments [3]. In addition, delayed diagnosis of pregnancy upon entry and unintended pregnancies during incarnation led to further delays in care [3]. Several studies, however, have suggested that incarceration can lead to improved maternal and neonatal outcomes due to improved shelter, access to meals, and decreased drug use compared with the community [4]. This pandemic will add additional barriers to care that will neutralize any gains that may have been seen with improved maternal outcomes.

There is much attention to the pandemic that has devastatingly impacted the international community, with greater impact on incarcerated women. Although pregnancy may not increase the risk for severe illness associated with COVID-19, the circumstance of incarceration compounds the dangers associated with pregnancy. We now know that the SARS-CoV-2 coronavirus of 2019 is highly infectious and may cause severe acute respiratory syndrome and death. Prisons, jails, and detention centers that sequester pregnant women in close quarters with limited protective equipment, increase the likelihood of infection. In addition, incarcerated pregnant women are likely to have other social determinants of health that increase their medical risk and psychological trauma. Data from the CDC suggest that symptomatic pregnant patients are at higher risk of severe illness and ICU admission with need for mechanical ventilation than their non-pregnant counterparts [5]. Patients who have concurrent comorbidities, such as diabetes, cardiovascular disease, or chronic lung disease, may be at an even greater risk of developing severe illness [5].

Consider the story of Andrea Circle Bear, a 30-year-old American woman who was incarcerated for a drug charge. She spent the last few days of her pregnancy in a local jail and later a federal prison. Andrea Bear died in prison from COVID-19 just 28 days after she gave birth [6]. This prompted many politicians to demand change from the government to allow pregnant inmates with minor offenses to be released during this difficult time; however, many states have not been successful in completing this task [6]. Many advocates argue that Bear's death was highly preventable and can be used as a catalyst for reforms to the criminal justice systems worldwide. For many countries, releasing prisoners to reduce overcrowding was an early first step. Others included quarantine and enforcing social distancing.

Healthcare providers and lawmakers must work together for the development and implementation of policies and standard-of-care recommendations that will provide safety for pregnant incarcerated women during this pandemic. These pregnancies must be considered high risk and these women deserve the same attention as their non-incarcerated counterparts. Providing access to prenatal visits, including telehealth visits, will likely improve prenatal care and wellbeing for this vulnerable population during the pandemic [3]. Telemedicine offers a cost-effective way to deliver timely healthcare in a population that is currently being starved of care [7]. Telemedicine can include videoconferencing, phone calls, or even email communication [7]. Facilities need to find ways to secure technological resources to accomplish these visits and ensure routine prenatal visits are being scheduled with providers.

Additionally, efforts need to be made to employ policies that maintain appropriate hygiene, such as routine hand washing and access to sanitizers. Inmates should have access to masks, and an emphasis should be placed on social distancing. These facilities need to work with the government to secure resources for increased testing of both inmates and facility workers. Any positive test should result in self-quarantine at the facility or released for home quarantine if uninfected.

At a period when COVID-19 vaccines are being released, pregnant incarcerated women should not be left out of the conversation. When sufficient doses are available, this group should be offered the vaccine. Like any other treatment during pregnancy, the benefits and risks of vaccination must be weighed, and the appropriate decision made after discussion with the healthcare provider. This high-risk population needs to have continued access to a provider during these uncertain times when there is still much to be learned about COVID-19 and the new vaccines. They need proper education, support, and guidance to make the appropriate decision.

Providing educational resources is an extremely important way to decrease the barriers to healthcare for this population. COVID-19 may not only exacerbate prior existing psychological trauma, but also mental health disorders. Incarceration is a particularly stressful time for a pregnant woman and her family [3]. Contributing to this burden are the unknowns of pregnancy and the postpartum period; add a major pandemic to the mix and one can only imagine how these incarcerated women are suffering. Access to mental health providers can be improved with telemedicine. Incarcerated women deserve the same education and counseling regarding their reproductive rights and pregnancies as those not incarcerated. As healthcare providers, we need to begin finding solutions on how to provide these educational resources.

As challenging as it may be during one of the most difficult times in our world, healthcare providers, prison facilities, and the government and lawmakers, need to all work closely together to find solutions to these problems and improve care for this vulnerable population, even during a pandemic.