Women & Health, 54:816–842, 2014 Copyright © Taylor & Francis Group, LLC ISSN: 0363-0242 print/1541-0331 online DOI: 10.1080/03630242.2014.932894

Mental Health Issues Among Pregnant Women in Correctional Facilities: A Systematic Review SOUMYADEEP MUKHERJEE, MBBS, DPH, DUDITH PIERRE-VICTOR, MPH, and RAED BAHELAH, MD, MPH, TM Department of Epidemiology, Robert Stempel College of Public Health & Social Work, Florida International University, Miami, Florida, USA

PURNIMA MADHIVANAN, MBBS, MPH, PhD Department of Epidemiology, Robert Stempel College of Public Health & Social Work, Florida International University, Miami, Florida, USA; and Public Health Research Institute of India, Yadavgiri, Mysore, India

Incarceration-induced stress makes pregnant women in correctional facilities a high-risk group for mental health problems, resulting in adverse maternal and fetal outcomes. A systematic review was conducted to examine the prevalence and correlates of mental health issues among pregnant inmates. Databases searched included PubMed, Medline, CINAHL Plus, PsycINFO, National Criminal Justice Reference System, Social Work Abstracts, Cochrane and Campbell libraries, which were searched for studies published in English from 1950 till July 2013. Eleven studies were included of pregnant women in correctional facilities and addressed at least one mental illness. Quality score was assigned to these eligible articles. Due to heterogeneity, a narrative review was performed. All of the studies were conducted in the United States, with quality scores ranging from 7 to 10 out of 10. Only one of these studies used mixed methods, the rest were quantitative. Tobacco use among pregnant inmates exceeded 50%, with some studies reporting as high as 84%. Alcohol use was common; 36% of the inmates used illicit drugs in one study. Depression and anxiety levels were high—some studies reported depression among 80% of inmates. Findings suggest that mental health among Received September 28, 2013; revised March 2, 2014; accepted March 26, 2014. Address correspondence to Soumyadeep Mukherjee, MBBS, DPH, Department of Epidemiology, Robert Stempel College of Public Health & Social Work, Florida International University, 11200 SW 8th Street, Miami, FL 33199. E-mail: [email protected] 816

Mental Health Among Pregnant Incarcerated Women

817

pregnant prisoners is a huge concern that has not been adequately addressed. KEYWORDS mental health, pregnant, incarceration, correctional, systematic review

BACKGROUND The supervision of “persons arrested for, convicted of or sentenced for criminal offenses” is described as corrections (BJS, 2013). A correctional facility is any place where a convict of criminal offence is held in custody under legal process, or lawful arrest in order to be punished, corrected, or rehabilitated (RCW, 2013). Correctional facilities include jails, prisons, or any other secure place, where convicts are confined (USLegal, 2013). The number of women and girls in penal institutions worldwide, including remand and convicted prisoners, was more than 625,000 in 2012; a 16% increase as compared to 2006. In most countries, female prisoners constitute between 2–9% of the total prison population (Walmsley, 2012). The median prevalence of female inmates within the total prison population is 3.1% in the African countries, 5.2% in the Americas, 6.0% in Asia, 4.9% in Europe, and 4.0% in Oceania (Walmsley, 2012). Countries vary widely in the proportion of female prisoners within the total prison population. For example, it is 5.1% in China, 4.1% in India, 8.8% in the United States (U.S.), 4.7% in England and Wales, and 7.0% in Australia (Walmsley, 2012). The U.S. accounts for the maximum number of female prisoners with approximately one-third of all female prisoners worldwide incarcerated in the U.S. prisons, followed by China, the Russian Federation, Brazil, and Thailand (Walmsley, 2012). The World Health Organization (WHO) describes mental health as “a state of well-being” that allows individuals to realize their own abilities and adjust with daily life’s stresses. Mental disorders, characterized by any combination of alterations in thoughts, emotions, behavior, and interpersonal relationships (WHO, 2008), are extremely common among female offenders, with an estimated 30% to 84% of them suffering from mental health disorders (Steadman et al., 2009; Tye & Mullen, 2006). Substance abuse, anxiety, depression, and post-traumatic stress disorder (PTSD) are common mental disorders among female inmates (Steadman et al., 2009; Tye & Mullen, 2006). Incarcerated women have a significantly higher incidence of schizophrenia, major depression, substance use disorders, psychosexual dysfunction, and antisocial personality disorder (Bloom & Covington, 2008). According to a special report of the Bureau of Justice Statistics published in September 2006, the rates of mental health problems among female inmates in the United States were higher than that of their male counterparts. The rates were 61% for females and 44% for males in Federal prisons; 73% and 55% in

818

S. Mukherjee et al.

State prisons; 75% and 63% local prisons for females and males respectively (James & Glaze, 2006). In England and Wales, 90% of women in prison suffer from at least one of neurosis, psychosis, or personality disorder, alcohol abuse or drug dependence (Møller et al., 2007). About 10–33% of pregnant women worldwide suffer from mental health problems, which contribute to maternal morbidity and mortality (WHO, 2008). Maternal stress, anxiety and depression contribute to non-compliance with antenatal care, miscarriage (Alder et al., 2007; Grote et al., 2010), preterm delivery, low birth weight (Steer et al., 1992), preeclampsia (Kurki et al., 2000), and lower rates of breastfeeding initiation (Grigoriadis et al., 2013). Antenatal mental distress also leads to unhealthy behaviors and poor nutrition (Zuckerman et al., 1989), postnatal depression (Andersson et al., 2002), and impaired future development of the child (Cao et al., 2012). More than three-quarters of all incarcerated women are in their childbearing years (Safyer & Richmond, 1995). Nearly 8–10% of women entering prisons are pregnant (Weatherhead, 2003) and less than half of the correctional facilities provide adequate perinatal care and other maternal support (Pollock, 1998; U.S. Dept of Justice, 1998). Moreover, pregnant women in correctional facilities have a double share of risks for psychosocial distress (Fogel & Belyea, 2001). A study reported over 70% of pregnant prisoners during their 3rd trimester suffered from clinical depression. Besides having a low social support, almost half of pregnant inmates lost an important relationship within the previous year and, most of them (80%) were not in a romantic relationship when they were interviewed (Fogel & Harris, 1986). This could increase the chances of such women being single parents and consequently being deprived of the necessary emotional support during pregnancy. A previous systematic review of pregnancy outcomes among imprisoned women used studies published up to 2005 and focused on fetal-related outcomes including miscarriages, fetal anomalies, preterm labor, and low birth weight (Knight & Plugge, 2005a). A review, which included articles published between 1980 and May 2004, assessed the risk factors for adverse outcomes among pregnant imprisoned women (Knight & Plugge, 2005b). Another systematic review, addressing the effectiveness of antenatal care programs in reducing the adverse perinatal outcomes among vulnerable female population from high-income countries, included articles published between 1990 and 2008 (Hollowell et al., 2011). However, none of these reviews specifically addressed mental health issues among female prisoners. Although, a meta-analysis explored the prevalence of severe mental illnesses (psychotic disorders and major depression) among prisoners worldwide, it included only studies in which psychiatric disorders were clinically diagnosed based on ICD or DSM criteria (Fazel & Seewald, 2012). While this approach may have a high specificity, it excludes all studies estimating depression by self-reported symptoms of mental illnesses. A vast majority of people reporting symptoms of mental illness may have not been assessed by

Mental Health Among Pregnant Incarcerated Women

819

any scale using the ICD or DSM diagnostic criteria. For example, 11–12% of adult females in the U.S. have self-reported frequent mental distress, which is based on self-report of 14 or more mentally unhealthy days in the previous 30 days (CDC, 2012c). On the other hand, using the Kessler-6 scale to measure depression, the prevalence of psychological distress in the U.S. has been reported in approximately 4% of adult women (Pratt et al., 2007). Mentally unhealthy days, which is used to calculate the prevalence of frequent mental distress, is one of the measures used in population surveys by the Centers of Disease Control and Prevention (CDC) to assess health related quality of life. The extent of mental health issues during pregnancy (Bennett et al., 2004; Ross & McLean, 2006), the high prevalence of mental problems among prisoners in general (Fazel & Danesh, 2002) and female prisoners in particular (James & Glaze, 2006) highly predispose imprisoned pregnant women to ill-mental health. These women are a highly vulnerable group, yet there is no systematic review addressing their mental health issues. The aim of this systematic review was to examine the prevalence and correlates of mental health issues among pregnant women in correctional facilities worldwide. Jail, prison, and any other place where a convict of a criminal offence is kept confined has been considered as a correctional facility (USLegal, 2013). Our review included all studies of pregnant women, regardless of age and country, with mental illnesses as diagnosed by standardized criteria (ICD, DSM) or self-reports by study subjects.

METHODS Search Strategy A review protocol form containing details of the methodology used in this systematic review is available with the first author. The authors conducted an extensive electronic search for all published articles from 1950 up to July 2013, using keywords and MeSH terms mentioned in the search string in Box 1. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed in conducting the systematic search and reporting the findings of the review (Moher et al., 2009). Databases including PubMed, Medline via ProQuest, CINAHL Plus with full texts, PsycINFO, National Criminal Justice Reference Service Abstracts Database, Social Work Abstracts and Cochrane and Campbell libraries were searched. Two reviewers independently searched each of the databases, after an initial verification of the search string by running against a known subset of papers. The titles and abstracts of all results were screened for any research that contained data addressing mental health problems among females in correctional facilities. The initial list was highly sensitive. If the title and abstract were in English and indicated that an article might include some data relevant to the research question, it was included and its full

820

S. Mukherjee et al.

BOX 1 Search Terms Used mental OR depression OR depressive OR depressed OR anxiety OR anxious OR distress∗ OR psychotic OR psychosis OR neurotic OR neurosis OR adjustment OR deliri∗ OR dement∗ OR amnesi∗ OR cogniti∗ OR Dissociative OR eating OR mood OR “sleep disorder” OR “sleep disorders” OR insomnia OR substance OR psycholog∗ OR psychiatr∗ OR behavior∗ OR obsess∗ OR personality OR suicide∗ OR emotion∗ OR “mental stress” OR “psychological stress” OR conduct OR impulse OR “sexual disorder” OR “panic” OR phobi∗ OR schizophreni∗ OR mania OR manic OR bipolar AND pregnant OR pregnancy OR antenatal OR peripartum OR perinatal OR expect∗ OR mother OR maternal OR childbirth OR prenatal AND incarcerat∗ OR prison∗ OR jail OR “correctional facility” OR “correctional facilities” OR “correctional supervision” OR “correctional system” OR confine∗ OR imprison∗

text retrieved. Furthermore, reference lists of these articles were manually examined, and articles considered potentially relevant were also included in the list. Although only original studies were considered for review, systematic reviews, commentaries and opinions published in peer-reviewed journals were included in this initial list to review their bibliographies. If more than one eligible study was identified based on the same sample, all of them were included, making a note that they were based on the same sample.

Study Selection RefWorks software was used to manage the database search results. After checking the list for any duplicate entries and removing them, two reviewers independently examined the accumulated citations for relevance, and reviewed full-text articles using the pre-specified eligibility criteria (Table 1). If a study sample included pregnant women of any age in correctional facilities and addressed any mental health issue, it was considered eligible. Systematic reviews, articles with full texts in a non-English language and case studies were excluded. Those articles that met the criteria were selected for the review. In case of any disagreement between the authors, decision was reached by mutual consensus or by a third reviewer. Although the plan was to contact authors of the articles to clarify any doubts, such a necessity did not arise.

Assessment of Quality of the Studies Subsequently, a quality score was assigned to each article using a modified version of assessment tools developed by Kmet, Lee, and Cook (2004). Separate criteria were used for qualitative and quantitative studies. Clear description of the research question or objective, appropriateness of the study design, clear description of data collection and data analysis methods

Mental Health Among Pregnant Incarcerated Women

821

TABLE 1 Selection Criteria for Studies Inclusion criteria All of the following: 1. Study sample includes women of any age who are in correctional facilities. 2. The article gives information about (some) women in the sample being pregnant at the time of the study. 3. Address at least one of (adapted from DSM-5 classification: http://dsm.psychiatryonline. org/book.aspx?bookid=556) • Anxiety disorders, including, generalized anxiety disorder, panic disorder, obsessive compulsive disorder, post-traumatic stress disorder, and phobias. • Bipolar disorder • Depression, including major depressive disorder, dysthymic disorder. • Personality disorders • Psychotic disorders, including schizophrenia • Substance abuse or substance dependence (including alcohol and tobacco) • Eating disorders • Posttraumatic stress disorder • Any kind of dissociative disorder • Any kind of sexual disorder • Sleep disorders, including insomnia • Adjustment disorders • Stress disorders • Impulse-control and conduct disorders • Cognitive disorders • Any other condition related to cognition, emotion, or behavior.

Exclusion criteria At least one of: 1. If no useful data can be extracted from the paper-studies for which full text cannot be obtained 2. The abstract is in English, but not the full text 3. Case studies 4. Systematic reviews

5. Women were under supervision in their own community.

were some of the criteria. These criteria have been described in detail in Table 2. A score of 1 was assigned if an article satisfied each of these criteria, with an overall score out of 10. Scoring for each article was performed by two reviewers independently, and in case of disagreement decision was made by consensus or a third reviewer. However, quality score was not used as an exclusion criterion for the review.

Data Extraction Data from the included articles were extracted using a standardized form ® designed in Microsoft excel. The information extracted from each study included the first author and year of study, place and year of study, study design, participants, sample size, purpose of the study, main results relevant to our review and quality score. Information on any summary measure, such as, means and proportions, risk ratio were included in the extraction form.

822

S. Mukherjee et al.

TABLE 2 Quality Assessment Criteria (Modified from Kmet, Lee, & Cook, 2004) Checklist for assessing the quality of quantitative studies: • Question/objective sufficiently described? • Study design evident and appropriate? • Method of subject/comparison group selection or source of information/input variables described and appropriate? • Subject (and comparison group, if applicable) characteristics sufficiently described? • Outcome and (if applicable) exposure measure(s) well defined and robust to measurement/misclassification bias? means of assessment reported? • Analytic methods described/justified and appropriate? • Some estimate of variance is reported for the main results? • Controlled for confounding? • Results reported in sufficient detail? • Conclusions supported by the results? Checklist for assessing the quality of qualitative studies • • • • • • • • • •

Question/objective sufficiently described? Study design evident and appropriate? Context for the study clear? Connection to a theoretical framework/wider body of knowledge? Sampling strategy described, relevant and justified? Data collection methods clearly described and systematic? Data analysis clearly described and systematic? Use of verification procedure(s) to establish credibility? Conclusions supported by the results? Reflexivity of the account?

Note. 1 score for each point, total score out of 10.

Definitions Used For the purpose of this review, a mental health condition was considered any alteration in self-reported thought, emotion or behavior (WHO, 2008), including anxiety disorders, bipolar disorder, depressive disorders, personality disorders, psychotic disorders, substance use, eating disorders, post traumatic disorders, adjustment disorders and stress disorders (American Psychiatric Association, 2013). Any female who was pregnant and confined in a jail or prison or other secured place at the time of the study was considered as a pregnant woman in a correctional facility (USLegal, 2013). If a study included some participants who were pregnant women in correctional facilities and were diagnosed with or self-reported any mental health issue, that study was included in this review.

Data Synthesis Data were tabulated and discussed in a narrative review. The studies eligible for this systematic review comprised of different research designs and research methods. Because of the heterogeneity of the studies, no attempts were made to pool quantitative results for meta-analysis.

Mental Health Among Pregnant Incarcerated Women

823

RESULTS Results of Search Strategy This search strategy resulted in 7,386 papers from all of the databases. After removing of duplicates and reviewing the titles and abstracts, 2,071 articles were shortlisted to be assessed for eligibility. Based on the eligibility criteria, 237 full texts were selected for second screen (Figure 1). The reference lists of the 237 articles were examined, 9 additional articles deemed relevant were selected, yielding a total of 246 articles. The full-texts of these articles were reviewed. In 153 articles, women included in the sample were not pregnant at the time of the study. Mental health issues of the inmates were not addressed in 49 other articles. Moreover, 21 articles examined inmates’ mental health while they were entering prison but did not address the mental health issues of those already in prison. In addition, the search revealed four case studies, which were excluded. Two other studies included women kept under supervision in their own community, but not in a jail or prison and six of the articles were systematic reviews. After excluding all these, 11 articles were included in the systematic review (Barkauskas, Low, & Pimlott, 2002; Bell et al., 2004; Clarke et al., 2010; Cordero et al., 1992; Egley et al., 1992; Eliason & Arndt, 2004; Fogel, 1993, 1995; Hutchinson et al., 2008; KyeiAboagye, Vragovic, & Chong, 2000; Terk, Martens, & Williamson, 1993).

Description of the Studies All of the selected studies (Table 3) were conducted in the United States, and seven of them were completed prior to 2000. One study using mixed-methods (Hutchinson et al., 2008) was included, and the rest were quantitative. The quality scores ranged from 7 to 10, which was the maximum possible score. Although tobacco, alcohol and other substance use were the most frequently addressed issues, few also addressed depression and/or anxiety.

Substance Use Tobacco use was frequent among the incarcerated pregnant women. The prevalence of smoking was more than 50% in most of the studies (Fogel, 1993, 1995; Egley et al., 1992) while a few of them had a prevalence higher than 75% (Barkauskas, Low, & Pimlott, 2002; Kyei-Aboagye, Vragovic, & Chong, 2000). Additionally, smoking was higher among incarcerated compared with non-incarcerated pregnant women (Terk, Martens, & Williamson, 1993). Women with a history of prior incarceration were more likely to report alcohol use compared with those with no history of previous incarceration (Clarke et al., 2010). About 15% of pregnant incarcerated women

824

S. Mukherjee et al.

FIGURE 1 Results of the search strategy.

consumed alcohol during their current pregnancy (Fogel, 1993). However, Kyei-Aboagye and colleagues reported a much higher prevalence (62%) of alcohol consumption during pregnancy (Kyei-Aboagye, Vragovic, & Chong, 2000).

825

Place of study

Bell (2004)

Washington, US

Barkauskas (2002) Large, Midwestern metropolitan area in the US

First author, year

Study design

1994–1998 Retrospective cohort

1996–1998 Communitybased experimental

Study year

Participants

Sample size

Purpose

(Continued)

10

8

Main results relevant to Quality our review score

Incarcerated 37: in Describe the 88% of women in the pregnant women residential development of a residential program with histories of program; residential and 84% in the drug abuse serving 35: in program for comparison group short-term comparison pregnant smoked during sentences in a group drug-dependent pregnancy. community women and residential present selected program; health outcomes. comparison group had similar women in prisons Women in jail for 496 births to Study the The proportion of part of their incarcerated association of women using alcohol pregnancy were women incarceration was significantly compared with compared to during pregnancy higher among the non-incarcerated 4,960 births with infant birth incarcerated Medicaid-recipients in the weight, preterm pregnant women from the comparison birth and fetal (36.5%) compared to community group growth restriction. the comparison group (28.1%).

TABLE 3 Summary of the Studies Included in Systematic Review

826

Cordero (1992)

Clarke (2010)

First author, year

Ohio, US

Rhode Island, US

Place of study

Study design

1986–1990 Cross-sectional

1997–2002 Cross-sectional

Study year

Pregnant women who were jailed at the Ohio Reformatory for Women

Women entering the Rhode Island jail

Participants

TABLE 3 Summary of the Studies Included in Systematic Review (Continued)

233

269

Sample size

8

9

Main results relevant to Quality our review score

Understand Women having prior conception timing incarcerations were in newly significantly more incarcerated likely to have a pregnant women history of injection and the drug and alcohol use relationship of compared to women incarceration to with no prior post-release incarcerations. conception. Determine whether 70% of the pregnant adequate prenatal prisoners reported care impacts smoking more than perinatal 10 cigarettes/day outcome. throughout pregnancy. One third of these pregnant smokers smoked more than 40 cigarettes per day

Purpose

827

Egley (1992)

First author, year

Raleigh, North Carolina, US

Place of study 1988

Study year Retrospective cohort

Study design

Sample size

69 inmates; Inmates who 69 controls. received prenatal care and delivered. Comparison group: included pregnant women matched for age, race, parity, and date of entry into prenatal care but not in prison

Participants

(Continued)

7

Main results relevant to Quality our review score

Examine the 68% of incarcerated prenatal and women smoked perinatal cigarettes compared outcomes in a to 20% of the cohort of comparison pregnant group. 36% of the prisoners during a inmates reported 12-month period. using illicit drugs. Cocaine was most commonly abused. Heroin, marijuana, hydromorphone, and alcohol were also abused.

Purpose

828

Eliason (2004)

First author, year

Iowa, USA

Place of study

Study design

1996–2001 Cross-sectional

Study year Women offenders included in the database established by Iowa Medical and Classification Center personnel.

Participants

TABLE 3 Summary of the Studies Included in Systematic Review (Continued)

Purpose

7

Main results relevant to Quality our review score

1,213, of which Examine substance Approx. 36% and 85% 53 were use characteristics of the pregnant pregnant of pregnant and women reported non-pregnant psychiatric and women in an substance abuse Iowa prison problems respectively, irrespective of pregnancy status. IV drug use and multiple substance use were common. Crack cocaine and methamphetamine were used most commonly. Marijuana use was more common among pregnant women. There was no significant difference in the prevalence of psychiatric and substance use disorders between pregnant and non-pregnant incarcerated women.

Sample size

829

Fogela (1993)

First author, year

Southern state in the US

Place of study

Study design

1986–1989 Exploratory descriptive

Study year Pregnant women incarcerated in the third trimester of their pregnancy in the study period.

Participants 89

Sample size

(Continued)

7

Main results relevant to Quality our review score

Describe More than 50% of the incarcerated women smoked, pregnant women, more than 25% used their risk factors drugs and 15% and pregnancy consumed alcohol outcomes. during their current pregnancy. High-levels of anxiety and depression were reported. 30% of the women had higher than normal levels of anxiety, while 77% reported clinical depression.

Purpose

830

Fogela (1995)

First author, year

Southern state in the US

Place of study

Study design

1987–1989 Prospective design

Study year Pregnant women incarcerated in the third trimester of their pregnancy.

Participants

TABLE 3 Summary of the Studies Included in Systematic Review (Continued)

89

Sample size

7

Main results relevant to Quality our review score

To identify the More than 50% of the health problems women smoked, and health care more than 25% used needs of pregnant drugs, and 15% prisoners. consumed alcohol during their current pregnancy. 80% of the women reported clinical depression and 50% had anxiety scores 1 SD above the norm for adult working women. 40% reported little or no social support. The depression (CES-D) scores were significantly higher among primigravidas compared to multigravidas.

Purpose

831

Hutchinson (2008)

First author, year

Large Southeastern city in the US

Place of study 2006

Study year Mixed-methods

Study design Pregnant inmates in a correctional institution for women.

Participants 25

Sample size Identify the experiences of pregnant women in prison.

Purpose

9

(Continued)

Participants reported moderate depression and high hostility. Themes of separation, attachment, visitation, jealousy toward caregivers and cognitive coping had positive correlation with depressive symptoms.

Main results relevant to Quality our review score

832

Kyei-Aboagye (2000)

First author, year

Boston, US

Place of study

Study design

1993–1996 Retrospective cohort

Study year

Sample size

Purpose

Patients who 149 women in To compare birth outcomes in delivered at Boston total: incarcerated Medical Center at 31 of them women with a full-term. incarcerated, recent history of 47 enrolled drug use to in a non-incarcerated methadone women in a maintenance methadone program, maintenance 71: control program. group of randomly chosen women

Participants

TABLE 3 Summary of the Studies Included in Systematic Review (Continued)

Most of the patients who were incarcerated (76%) or on methadone maintenance therapy (96%) reported smoking, while it was much lower among the randomly selected patients. Nearly 62% of incarcerated women reported alcohol use. The incarcerated women were at slightly higher risk of having an LBW infant compared to the control group.

9

Main results relevant to Quality our review score

833

a

Study year

Study design

Galveston, Texas, 1987–1990 Retrospective US cohort

Place of study

Used the same sample.

Terk (1993)

First author, year

Sample size

Purpose

7

Main results relevant to Quality our review score

Women who 76 pregnant Assess the effects of Smoking and the use of delivered at the incarcerated incarceration on alcohol and illicit obstetric unit of women and pregnancy drugs, including University of Texas 117 randomly outcome. cocaine, heroin, Medical Branch. chosen methamphetamine, pregnant and multiple drugs, women not was higher among in prisons. incarcerated compared with non-incarcerated pregnant women.

Participants

834

S. Mukherjee et al.

Although roughly 60% of all pregnant women in U.S. prisons had a history of substance abuse, less than 50% of the correction systems had programs directed to those women (Burd et al., 2004). A study conducted in North Carolina reported 36% of the inmates used illicit drugs, and cocaine was the most commonly used drug (Egley et al., 1992). A 2004 study reported nine out of every ten women had substance use problems (Eliason & Arndt, 2004). Terk and colleagues found that cocaine, heroin, methamphetamine, and multiple drug use were higher among incarcerated compared to nonincarcerated pregnant women (Terk, Martens, & Williamson, 1993).

Depression and Anxiety An analysis of data from 1996 to 2001 found that nearly 36% of 53 pregnant women offenders in Iowa had psychiatric problems (Eliason & Arndt, 2004). Depression and anxiety levels were very high among pregnant women in the third trimester of their pregnancy (Fogel, 1993), and the depression scores were significantly higher among women who were pregnant for the first time (Fogel, 1995). In this study, psychological health was measured by the Center for Epidemiological Studies-Depression Scales (CES-D) and the Speilberger State Trait Anxiety Inventory for State Anxiety (STAI-S) (Fogel, 1995). Among pregnant incarcerated women in their third trimester, 80% and 50% had symptoms of clinical depression and anxiety, respectively, with 40% having little or no social support from family and friends during imprisonment. The mean depression and anxiety scores were 27.26 (SD: 10.98) and 43.37 (SD: 7.03), respectively (Fogel, 1995). Among pregnant inmates in a large south-eastern city in the US, depression and hostility were commonly reported (Hutchinson et al., 2008). The mean score for the Brief Symptom Inventory (BSI) hostility scale was 64 (SD: 63), almost one and half standard deviations higher than normal. For the BSI anxiety subscales, the mean score of 58 (SD: 58) was in the high average range, while the average Beck Depression Inventory (BDI) score of 21.17 (SD: 9.36) indicated moderate depression (Hutchinson et al., 2008). The themes of fear of separation, jealousy and ambivalence toward the caregiver had positive correlation with BDI scores (Hutchinson et al., 2008).

DISCUSSION All the studies found eligible for this systematic review, had been conducted in the U.S. The quality scores of these articles ranged from 7 to 10 out of 10. Most of the studies were quantitative, with one using mixed methods. Tobacco use among pregnant inmates ranged from 50–84%. Use of alcohol and illicit drugs, and mental health issues, especially depression and anxiety, were frequently reported. The U.S. has the highest worldwide incarceration

Mental Health Among Pregnant Incarcerated Women

835

rate of 716 per 100,000 population, as well as the highest number of prisoners, exceeding 2.2 million in 2011 (ICPS, 2013b). Nearly one-third of the 625,000 women and girls held in penal institutions worldwide live in the U.S., which has the highest number of female prisoners among all the countries in the world (Walmsley, 2012). Approximately 9% of all prisoners in the US are women (ICPS, 2013a). From the studies included in this review, with the years of publication ranging from 1992 to 2010, it is evident that incarceration of pregnant women continues despite discouragement by the United Nations Office on Drugs and Crime (UNODC) (WHO et al., 2011). Tobacco use among pregnant women in correctional facilities is much higher compared with tobacco use (less than 17%) among the nonimprisoned adult females in the U.S. (CDC, 2012a). Other studies, not eligible for our review, found that 80–83% of the women in Australian and American prisons were smokers (Belcher et al., 2006; Nijhawan et al., 2010). Comparison of the proportion of female prisoners who smoke with the proportion of smokers among pregnant inmates suggests that pregnancy does not result in a substantial change in their smoking habits. This is in contrast to estimates from the general female population- nearly half of all smokers quit smoking during pregnancy (CDC, 2013). About 15–62% of incarcerated women consumed alcohol during their current pregnancy (Fogel, 1993, 1995; Kyei-Aboagye, Vragovic, & Chong, 2000). A previous systematic review found 10–24% of female prisoners suffered from alcohol abuse and dependence (Fazel & Seewald, 2012). The estimates of reported alcohol use ranged from 8 to 15% among pregnant women in the U.S. population (CDC, 2012b). Rates of alcohol use among pregnant women in prisons do not indicate that pregnancy leads to a decrease in alcohol use among incarcerated women. The overall substance use among incarcerated pregnant women ranged from 60–90%, with illicit drug use being commonly reported (Burd et al., 2004; Eliason & Arndt, 2004). About 70% of the female inmates were dependent on at least one substance (Proctor, 2012). Therefore, the prevalence of substance use among incarcerated pregnant women is considerably higher than the 5% among pregnant women in the general U.S. population (SAMHSA, 2012). A review of the risk factors for adverse perinatal outcomes among mothers revealed that 66%, 20%, and 50% of the imprisoned pregnant women smoked, used alcohol, and illegal drugs, respectively (Knight & Plugge, 2005b). Irrespective of pregnancy status, incarcerated women were more likely than incarcerated males to have extensive history of physical, sexual, and emotional abuse (Messina et al., 2006). In addition, women in prison had higher rates of mental disorders compared to women in the general population (Teplin, Abram, & McClelland, 1996; Tye & Mullen, 2006). While approximately 12% of females in the general population had symptoms of a mental disorder, it was 60–75% among female prisoners (James & Glaze,

836

S. Mukherjee et al.

2006). Among incarcerated women, a strong relationship exists between childhood abuse and adult mental health problems (Messina & Grella, 2006). The studies included in our review indicate that the simultaneous presence of two stressors, pregnancy and incarceration, render incarcerated pregnant women extremely vulnerable to mental health issues including substance use. However, females are more likely to be imprisoned due to drug and property offenses than their male counterparts (Carson & Sabol, 2012). This suggests that drug and alcohol use might actually be a cause of some women getting imprisoned. Substance use among female inmates is not necessarily a consequence of their incarceration. Psychological implications of childbearing in prison depend on the prison environment and psychosocial characteristics of the prisoners. Higher levels of stress, restrictiveness in the environment, altered social support, and maternal role displacement are among the important psychosocial needs particular to pregnant incarcerated women (Hufft, 1992). Perceived lack of adequate medical care, isolation, stress, fear, maternal role transition, and parenting concerns were common themes stated by incarcerated pregnant women during interviews (Baunach, 1985; Feinman, 1994; Fogel & Harris, 1986; Hufft, 1992; Shelton & Gill, 1989; Shelton, Armstrong, & Cochran, 1983). Moreover, anger, regret, and depression regarding potential separation from and inability to care for their infants were frequently reported and often led to a psychological distance of the expectant mother from her fetus (Shelton & Gill, 1989). The use of shackles and restraints among pregnant women in correctional facilities often limits movement and the ability to change positions, resulting in severe mental anguish, physical pain, and injury (Women and Prison, 2010), which can pose serious threats to the lives of the woman and her baby (ACOG, 2011).

LIMITATIONS This review had several limitations. Studies used different methods leading to heterogeneity of the studies and preventing comparability. Furthermore, most studies were cross-sectional and thus only collected data at one point in time, making it impossible to assess the temporal sequence of imprisonment and mental health issues, specifically whether imprisonment led to mental health issues during pregnancy, or whether mentally ill and substance using women were more likely to end up in prisons. Most studies were not designed to address our specific research question; hence the instruments used in those studies might not have been suitable to examine our review question. Another limitation was that additional literature such as reports, commentaries, and conference presentations or proceedings, which might have provided useful information, were not included. We limited our review only to original research studies published in peer-reviewed scholarly

Mental Health Among Pregnant Incarcerated Women

837

journals to ensure reliability of their findings. Also, the articles included in the review spanned over about two decades (1992 to 2010). As a consequence, the socio-economic-political scenario may differ widely among the studies. Finally, most of the studies did not adjust for potential confounders; hence it is not possible to attribute the morbidities to incarceration with certainty.

CONCLUSION AND IMPLICATIONS Despite its limitations, this review is probably the only one addressing mental health issues in a specific subgroup of incarcerated women—those who were pregnant. The databases searched included health, psychiatry, and criminal law, and the search string and terms were exhaustive. Four of the 11 studies were designed to assess the characteristics, experiences, and substance use among pregnant women in correctional facilities (Eliason & Arndt, 2004; Fogel, 1993, 1995; Hutchinson et al., 2008). The findings from various studies suggest that mental health issues among pregnant inmates are challenging. The perinatal outcomes associated with these illnesses and risk behaviors raise serious concerns because of low physical activity and nutritional problems that can only be worse in the correctional population (Shaw, 2012). It might be useful to investigate the role played by prison environment behind their mental problems. Even though our focus was on the whole world and the search for eligible studies did not preclude any country, all of the studies that met our eligibility criteria were conducted in the U.S. This appears to be an important gap in existing research on mental health of pregnant inmates, which future studies should address. This could be of concern for countries like China, Russian Federation, Brazil, Thailand, and India, which have a very large number of female prisoners following the U.S. (Walmsley, 2012). The proportion of female prisoners in the prison system of Hong Kong-China, Macau-China, Bahrain, Andorra, Maldives, Qatar, and Thailand are higher than the proportion in the US (Walmsley, 2012; BJS, 2013). Although prison related statistics of most of the other countries are not as up-to-date as those in the U.S., the proportion of female prisoners in the prison systems do indicate a pressing need to investigate the prevalence of mental health disorders and their outcomes among incarcerated females in these countries. The review highlights critical gaps in the literature, including few longitudinal studies to examine the temporal relationship between imprisonment and mental health among pregnant women. According to the recommendations of the WHO and UNODC, prison health service should address mental illness, with special emphasis on substance abuse and post-traumatic stress disorder (WHO et al., 2011). It also stated that the gender-specific health care needs of female inmates should be met in a humane manner. The UNODC mandated special care for pregnant

838

S. Mukherjee et al.

women who are imprisoned, including more flexibility of the prison regime and application of minimum restraints, especially during examinations and childbirth (Atabay, 2008). Stronger evidence regarding the causal relationship of imprisonment during pregnancy and mental health outcomes will help to facilitate changes in policy in order to implement these recommendations. The benefits of the UNODC recommended policy of diverting women, responsible for minor and non-violent offences, from traditional prisons to appropriate treatment or restorative justice programs should also be evaluated to provide a wider variety of options for police, prosecutors and the court. Providing rehabilitative services for such inmates, instead of keeping them in correctional facilities, will not only facilitate reintegration into the society but will also result in better pregnancy and mental health outcomes. However, this also needs to be evaluated more rigorously.

ACKNOWLEDGMENT The authors would like to gratefully acknowledge the valuable input regarding search terms and databases from Barbara M. Sorondo, the Health Sciences Librarian at Florida International University.

REFERENCES ACOG. 2011. Health care for pregnant and postpartum incarcerated women and adolescent females. Committee Opinion No. 511. American College of Obstetricians and Gynecologists. Obstet Gynecol 118:1198–1202. Alder, J., N. Fink, J. Bitzer, I. Hösli, and W. Holzgreve. 2007. Depression and anxiety during pregnancy: A risk factor for obstetric, fetal and neonatal outcome? A critical review of the literature. J Matern-Fetal Neonat Med 20(3):189–209. American Psychiatric Association. 2013. Diagnostic and statistical manual of mental disorders, 5th ed. DSM Library. Retrieved August 24, 2013, from http://dsm. psychiatryonline.org/book.aspx?bookid=556 Andersson, L., Sundström-Poromaa, I., Wulff, M., Aström, M., and Bixo, M. 2002. Depression and anxiety during pregnancy and six months postpartum: A followup study. Acta Obstet Gynecol Scand 85:937–44. Atabay, T. 2008. Handbook for prison managers and policymakers on women and imprisonment. New York, NY: United Nations Publications. Barkauskas, Vi. H., L. K. Low, and S. Pimlott. 2002. Health outcomes of incarcerated pregnant women and their infants in a community-based program. J Midwifery & Women’s Health 47(5):371–9. Baunach, P. J. 1985. Mothers in prison. New Brunswick, NJ: Transaction Books. Belcher, J., T. Butler, R. L. Richmond, A. D. Wodak, and K. Wilhelm. 2006. Smoking and its correlates in an Australian prisoner population. Drug Alcohol Rev 25(4):343–8.

Mental Health Among Pregnant Incarcerated Women

839

Bell, J. F., F. J. Zimmerman, M. L. Cawthon, C. E. Huebner, D. H. Ward, and C. A. Schroeder. 2004. Jail incarceration and birth outcomes. J Urban Health: Bull NY Acad Med 81(4):630–44. Bennett, He. A., A. Einarson, A. Taddio, G. Koren, and T. R. Einarson. 2004. Prevalence of depression during pregnancy: Systematic review. Obstet & Gyn 103(4):698–709. BJS. 2013. Jail inmates at midyear 2012. Statistical tables—jim12st.Pdf . Retrieved July 11, 2013, from http://www.bjs.gov/content/pub/pdf/jim12st.pdf Bloom, B. E., and S. Covington. 2008. Addressing the mental health needs of women offenders. In Women’s mental health issues across the criminal justice system, ed. Rosemary L. Gido and Lanette Dalley, 160–76. Upper Saddle River, NJ: Pearson Prentice Hall. Burd, L., R. Selfridge, M. Klug, and S. Bakko. 2004. Fetal alcohol syndrome in the United States corrections system. Addic Biol 9(2):169–76. Cao, X., D. Laplante, A. Brunet, A. Ciampi, and S. King. 2012. Prenatal maternal stress affects motor function in 51/2-year-old children: Project Ice Storm. Develop Psychobiol 56(1):117–25. Carson, A., and W. Sabol. 2012. Prisoners in 2011. Washington, DC: Bureau of Justice Statistics. CDC. 2012a. Current cigarette smoking among adults—United States, 2011. Centers for Disease Control and Prevention. Retrieved August 13, 2013, from http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6144a2.htm?s_ cid=%20mm6144a2.htm_w. CDC. 2012b. Fetal alcohol spectrum disorders (FASDs). Centers for Disease Control and Prevention. Retrieved August 18, 2013, from http://www.cdc.gov/ncbddd/ fasd/data.html201308/18. CDC. 2012c. Non-specific psychological distress. Centers for Disease Control and Prevention. Retrieved on August 13, 2013 from http://www.cdc.gov/ mentalhealth/data_stats/nspd.htm CDC. 2013. Tobacco use and pregnancy. Centers for Disease Control and Prevention. Retrieved August 18, 2013, from http://www.cdc.gov/reproductivehealth/ TobaccoUsePregnancy/ Clarke, J. G., M. Phipps, I. Tong, J. Rose, and M. Gold. 2010. Timing of conception for pregnant women returning to jail. J Correc Health Care 16(2):133–8. Cordero, L., S. Hines, K. A. Shibley, and M. B. Landon. 1992. Perinatal outcome for women in prison. J Perinatol: Official J California Perinatal Assoc 12(3):205–9. Egley, C. C., D. E. Miller, J. L. Granados, and C. Ingram-Fogel. 1992. Outcome of pregnancy during imprisonment. J Reprod Med 37(2):131–4. Eliason, M. J., and S. Arndt. 2004. Pregnant inmates: A growing concern. J Addic Nurs 15(4):163–70. Fazel, S., and J. Danesh. 2002. Serious mental disorder in 23 000 prisoners: A systematic review of 62 surveys. Lancet 359(9306):545–50. Fazel, S., and K. Seewald. 2012. Severe mental illness in 33 588 prisoners worldwide: Systematic review and meta-regression analysis. Brit J Psych 200(5):364–73. Feinman, C. 1994. Women in the criminal justice system. Westport, CT: Praeger Publishers. Fogel, C. I. 1993. Pregnant inmates. J Obstet, Gyn, & Neonat Nurs 22(1):33–9.

840

S. Mukherjee et al.

Fogel, C. I. 1995. Pregnant prisoners: Impact of incarceration on health and health care. J Correc Health Care 2(2):169–90. Fogel, C. I., and B. G. Harris. 1986. Expecting in prison: Preparing for birth under conditions of stress. J Obstet, Gyn, & Neonat Nurs 15(6):454–8. Fogel, C. I., and M. Belyea. 2001. Psychosocial risk factors in pregnant inmates: A challenge for nursing. Am J Maternal/Child Nurs 26(1):10–6. Grigoriadis, S., E. H. Vonderporten, L. Mamisashvili, G. Tomlinson, CL Dennis, G. Koren, et al. 2013. The impact of maternal depression during pregnancy on perinatal outcomes: A systematic review and meta-analysis. J Clin Psych 74(4):e321–41. Grote, N. K., J. A. Bridge, A. R. Gavin, J. L. Melville, S. Iyengar, and W. J. Katon. 2010. A meta-analysis of depression during pregnancy and the risk of preterm birth, low birth weight, and intrauterine growth restriction. Arch Gen Psych 67(10):1012. Hollowell, J., L. Oakley, J. J. Kurinczuk, P. Brocklehurst, and R. Gray. 2011. The effectiveness of antenatal care programmes to reduce infant mortality and preterm birth in socially disadvantaged and vulnerable women in high-income countries: A systematic review. BMC Preg Childbirth 11(1):13. Hufft, A. G. 1992. Psychosocial adaption to pregnancy in prison. J Psychosoc Nurs Mental Health Serv 30(4):19–22. Hutchinson, K. C., G. A. Moore, C. B. Propper, and A. Mariaskin. 2008. Incarcerated women’s psychological functioning during pregnancy. Psychol Women Quar 32(4):440–53. ICPS. 2013a. Entire world—Prison population rates per 100,000 of the national population. Retrieved August 18, 2013, from http://www.prisonstudies.org/info/ worldbrief/wpb_stats.php?area=all&category=wb_poprate ICPS. 2013b. Entire world—Prison population totals. Retrieved August 13, 2013, from http://www.prisonstudies.org/info/worldbrief/wpb_stats.php?area= all&category=wb_poptotal James, D. J., and L. E. Glaze. 2006. Mental health problems of prison and jail inmates. Washington, DC: U.S. Department of Justice, Office of Justice Programs, Bureau of Justice Statistics. Kmet, L. M., R. C. Lee, and L. S. Cook. 2004. Standard quality assessment criteria for evaluating primary research papers from a variety of fields. Alberta, Canada: Alberta Heritage Foundation for Medical Research. Knight, M., and E. Plugge. 2005a. The outcomes of pregnancy among imprisoned women: A systematic review. Int J Obstet & Gyn 112(11):1467–74. Knight, M., and E. Plugge. 2005b. Risk factors for adverse perinatal outcomes in imprisoned pregnant women: A systematic review. BMC Publ Health 5(1):111. Kurki, T., V. Hiilesmaa, R. Raitasalo, H. Mattila, and O. Ylikorkala. 2000. Depression and anxiety in early pregnancy and risk for preeclampsia. Obstet & Gyn 95(4):487–90. Kyei-Aboagye, K., O. Vragovic, and D. Chong. 2000. Birth outcome in incarcerated, high-risk pregnant women. Obstet & Gyn Surv 55(11):682–4. Messina, N., W. Burdon, G. Hagopian, and M. Prendergast. 2006. Predictors of prison-based treatment outcomes: A comparison of men and women participants. Am J Drug Alcohol Abuse 32(1):7–28.

Mental Health Among Pregnant Incarcerated Women

841

Messina, N., and C. Grella. 2006. Childhood trauma and women’s health outcomes in a california prison population. J Inform 96(10):1842–8. Møller, L., A. Gatherer, R. Jürgens, H. Stöver, and H. Nikogosian (Eds.). 2007. Health in prisons: A WHO guide to the essentials in prison health. Copenhagen, Denmark: WHO Regional Office Europe. Moher, D., A. Liberati, J. Tetzlaff, and D. G. Altman. 2009. Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement. Ann Intern Med 151(4):264–9. Nijhawan, A. E., R. Salloway, A. S. Nunn, M. Poshkus, and J. G. Clarke. 2010. Preventive healthcare for underserved women: Results of a prison survey. J Women’s Health 19(1):17–22. Pollock, J. M. 1998. Counseling women in prison. Thousand Oaks, CA: Sage Publications. Pratt, L. A., A. N. Dey, and A. J. Cohen. 2007. Characteristics of adults with serious psychological distress as measured by the K6 scale, United States, 2001–04. Hyattsville, MD: National Center for Health Statistics. Proctor, S. L. 2012. Substance use disorder prevalence among female state prison inmates. Am J Drug Alcohol Abuse 38(4):278–85. RCW. 2013. RCW 9.94.049: “Correctional Institution” and “State Correctional Institution” defined. Retrieved July 18, 2013, from http://apps.leg.wa.gov/rcw/ default.aspx?cite=9.94.049 Ross, L. E., and L. M. McLean. 2006. Anxiety disorders during pregnancy and the postpartum period: A systematic review. Depression 6:9. Safyer, S. M., and L. Richmond. 1995. Pregnancy behind bars. Seminars in Perinatology 19(4):314–22. SAMHSA. 2012. Results from the 2011 National Survey on Drug Use and Health: Summary of national findings. Retrieved August 18, 2013, from http://www. samhsa.gov/data/nsduh/2k11results/nsduhresults2011.htm Shaw, N. S., M. Rutherdale, and J. Kenny. 1985. Eating more and enjoying it less: US prison diets for women. Women & Health 10(1):39–57. Shelton, B. J., and D. G. Gill. 1989. Childbearing in prison: A behavioral analysis. J Obstet, Gyn, & Neonat Nurs 18(4):301–8. Shelton, B. J., F. Armstrong, and S. E. Cochran. 1983. Childbearing while incarcerated. Matern Child Nurs 8(1):23–24. Steadman, H., F. Osher, P. C. Robbins, B. Case, and S. Samuels. 2009. Prevalence of serious mental illness among jail inmates. Psych Serv 60(6):761–5. Steer, R. A., T. O. Scholl, M. L. Hediger, and R. L. Fischer. 1992. Self-reported depression and negative pregnancy outcomes. J Clin Epidemiol 45(10):1093–9. Teplin, L. A., K. M. Abram, and G. M. McClelland. 1996. Prevalence of psychiatric disorders among incarcerated women: Pretrial jail detainees. Arch Gen Psych 53(6):505–12. Terk, J. V., M. G. Martens, and M. A. Williamson. 1993. Pregnancy outcomes of incarcerated women. J Matern-Fetal Neonat Med 2(5):246–50. Tye, C. S., and P. E. Mullen. 2006. Mental disorders in female prisoners. Aust & N Zealand J Psych 40(3):266–71. U.S. Dept. of Justice. 1998. Women in Criminal justice: A twenty year update: Special report. Washington, DC: U.S. Dept. of Justice.

842

S. Mukherjee et al.

USLegal. 2013. Correctional facility law & legal definition. Retrieved July 18, 2013, from http://definitions.uslegal.com/c/correctional-facility/ Walmsley, R. 2012. World female imprisonment list, 2nd ed. London, England: King’s College/International Centre for Prison Studies. Weatherhead, K. 2003. Cruel but not unusual punishment: The failure to provide adequate medical treatment to female prisoners in the United States. Health Matrix 13:429. WHO. 2008. Improving maternal mental health. World Health Organization. Retrieved August 13, 2013, from http://www.who.int/mental_health/ prevention/suicide/Perinatal_depression_mmh_final.pdf WHO, UNODC, B. van den Bergh, A. Gatherer, T. Atabay, and F. Hariga. 2011. Women’s health in prison: Action guidance and checklists to review current policies and practices. Copenhagen, Denmark: WHO and UNODC. Women and Prison. 2010. Giving birth in chains: The shackling of incarcerated women during labor and delivery—Motherhood—Women and prison: A site for resistance. Retrieved July 18, 2013, from http://womenandprison. org/motherhood/view/giving_birth_in_chains_the_shackling_of_incarcerated_ women_during_labor_and/ Zuckerman, B., H. Amaro, H. Bauchner, and H. Cabral. 1989. Depressive symptoms during pregnancy: Relationship to poor health behaviors. Am J Obstet Gyn 160(5):1107–1.

Copyright of Women & Health is the property of Taylor & Francis Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.