The number of women imprisoned across the world is increasing. According to the World Female Imprisonment List, the number of female prisoners has increased worldwide by 53% since 2000 (Walmsley, 2017), with many of these women having dependent children (Epstein, 2014). This rise has been attributed to a change in sentencing, as many imprisoned women are on remand or serving short sentences for non-violent crimes (Prison Reform Trust, 2016). This therefore increases the possibility of childbirth during a prison sentence, with the risk of mother and baby being separated. This also affects mothers who already have young families, as evidence suggests that only 1 in 20 children with imprisoned mothers are cared for in the family home (Beresford, 2018). According to Birth Companions, a charity that works with women and babies in prison (Birth Companions, 2019), around 100 babies in England and Wales are born to women in prison every year (Kennedy et al, 2016). In the UK, women make up approximately 5% of the total prison population (Sturge, 2018), one of the highest rates of women in prison in western Europe (Prison Reform Trust, 2017).
Women in prison are a minority group, and usually have a complex history of abuse and/or mental illness, leading to high levels of pre-existing stress and anxiety (Corston, 2007; The Rebecca Project for Human Rights, 2010; Prison Reform Trust, 2017). These stresses can be further heightened when women are imprisoned while pregnant or caring for young children. Many of these women do not have the support to which they are entitled, despite national and international legislation to protect their health and wellbeing (Kennedy et al, 2016).
The UK is signatory to the United Nations Rules for the Treatment of Women Prisoners and Non-Custodial Measures for Women Offenders (also known as the ‘Bangkok Rules’) (United Nations Office on Drugs and Crime, 2010; Penal Reform International, 2013), which clearly sets out standards for the treatment of women prisoners and offenders. These rules were implemented by the UN General Assembly in 2010 to address the lack of regulations differentiating treatment between male and female prisoners. They are also the first international tool to recognise the needs of children in prison with their parent (Penal Reform International, 2013). In the UK, the Prison Act [1952] and the Prison Rules [1999] were introduced, setting out the expected standards for the management of prisons, as well as the treatment of prisoners.
There are 12 women's prisons in England, of which only half have mother and baby units (MBUs) (also known as ‘prison nurseries’) (Gov.uk, 2019). MBUs offer separate living accommodation within the prison, where mothers have full parental responsibility for the day-to-day care of their child (Prisoners' Advice Service, 2017). Children can stay with their mothers in an MBU until they are 18 months old. Not all mothers will gain a place in an MBU. This could be due to their history, but is more commonly due to women not being properly informed of the application process by prison services (Sikand, 2015). Women who give birth in prison could have their baby removed from them shortly after birth, and Social Services will arrange for babies to be cared for by a family member if deemed safe to do so, or be placed into foster care (Gov.uk, 2019).
Separating babies from their mothers is a controversial issue. It is well documented that separation may damage attachment, and therefore not only have a detrimental effect on the child's developmental outcomes (O'Keeffe and Dixon, 2015), but also on maternal mental health (Johnson, 2013).
It has also been suggested that the environment in which a child is brought up can shape their cognitive, social and behavioural development (Underdown and Barlow, 2012), and a prison is unlikely to be a suitable environment for a child. It is therefore essential that MBUs are suitable and well-equipped for children, as research has shown mothers and babies can thrive when in an MBU (Sikand, 2015).
Midwives are in a prime position to offer support to vulnerable women; however, this can prove to be difficult when women are imprisoned. There is a difference between the midwifery care provided to women in the community and the care that pregnant women in prisons receive, which has also been found to be inconsistent between prisons (Birth Companions, 2019). Although Better Births (National Maternity Review, 2016) is working towards providing care that enables women to make their own informed choices, a study by Abbott (2018) found that women in prison report feeling that their options for birth are out of their control. As a result, women in prison may make medicalised decisions, such as choosing a caesarean section rather than a natural birth, to have more control.
The Birth Charter for women in prisons in England and Wales (Kennedy et al, 2016) sets out recommendations to improve the conditions for pregnant women in prison and their babies. Birth Companions aim to support the prison service in delivering consistent and humane care to this group of women and mothers (Kennedy et al, 2016). The Royal College of Midwives (RCM) fully supports the work of the Birth Charter (Ewers, 2016), stating that if the work is fulfilled, it will make a considerable difference to the standard of care for these pregnant women and mothers. This will help to build a society in which all babies are given the best possible start in life.
Methodology
This study analyses research published in the past 10 years that examined mothers who gave birth in prison or resided in prison with their baby. The search focused on the experiences of women who cared for their babies while serving time in prison, and the effect it had on mothers and babies who were separated. Keywords for the search included: mothers, bab* (to capture ‘baby’ or ‘babies’), prison, ‘prison nursery’ and ‘mother and baby units’. An additional search using the Cochrane online library was then carried out, to identify if any recent literature had previously been conducted. There were no matches on Cochrane using the identified keywords.
These keywords and Boolean terms were then used to search appropriate electronic databases for mothers and bab* AND prison OR ‘prison nursery’ OR ‘prison mother and baby units’, using a university online search tool. Databases that were searched included, but were not limited to: ERIC, PsycINFO, CINAHL Complete, MEDLINE Complete and Academic Search Complete.
The initial search dated back 10 years and produced 1140 studies. After applying exclusion criteria, which included academic journals, peer-reviewed, full text and articles written in English, 77 papers were then identified. Once duplicates had been removed, this brought the total down to 37.
The remaining 37 papers were then screened by looking at the titles and abstracts. Studies that specifically identified mothers who had either given birth or had their babies with them in prison were kept, and during this process, a further 32 studies were discounted, leaving five articles. The full text was read and assessed for quality using either a Critical Appraisal Skills Programme tool (CASP) (2018), or the Holland and Rees (2010) framework for critiquing qualitative research articles. Two articles were then discounted due to lack of relevance.
Additional search strategies were also used, including reference list searching and reading key authors. This ensured that any literature that was not identified in the initial electronic database search was then acquired. One paper of interest was identified from this method. After reading, it was deemed not relevant to the topic area; however, it offered useful background information.
Results
Three papers that met the inclusion criteria were included in this review. A mixed-methods study (Goshin et al, 2014) analysed 3-year re-offending rates after women's release from an MBU, using data from two larger studies to measure outcomes among 139 women who resided with their infants in a New York state prison. This article examined maternal and child characteristics, in a cross sectional approach. The second study analysed by Goshin et al (2014) measured long-term mother and child outcomes. The main findings of the study were that a high proportion of women had history of depressive symptoms, and that women released from an MBU had a low likelihood of re-offending within 3 years.
A qualitative study by Chambers (2009) examined the impact of forced separation on incarcerated postpartum mothers. A total of 12 mothers were interviewed during the early postpartum period about their bonding relationships with their babies, both antenatally and postnatally. The interviews took place in a prison hospital in Texas. The findings were gathered into four themes, with the results used to inform policies on gender inequality in prisons.
A qualitative study by Rahimipour Anaraki and Boostani (2014) focused on mother and child interaction. This study took place in Iran and included 14 imprisoned women living with their child. The women were interviewed outside of the prison environment. The main findings of this study were compiled into six themes and one core category that explored mother and child interactions.
Two of the studies (Chambers, 2009; Rahimipour Anaraki and Boostani, 2014) used a qualitative research method. This approach was suitable as it aims to examine an individual's experience in the context of their environment (Polgar and Thomas, 2008), whereas Goshin et al (2014) used a quantitative approach. Including two different types of research can be seen as a strength of this literature review, particularly as there are common themes across the different research methods (Cluett and Bluff 2006). Both qualitative papers used purposive sampling, which could be a limitation due to low generalisability (Dudovskiy, 2019); however, purposive sampling is used by researchers to obtain participants who are best placed to provide high-quality data (Polgar and Thomas, 2008). Given the topic of these articles, this approach is probably best suited to address the research aims.
All the studies used small sample sizes, although in qualitative studies a small sample size is appropriate, as participants are sought to provide well-informed data (Aveyard, 2014). In both qualitative papers, recruitment stopped when saturation was accomplished. In the mixed-methods study (Goshin et al, 2014), a small sample size could limit validity (Aveyard, 2014), yet given the unusual circumstances of the participants, a larger sample might be difficult to obtain.
Goshin et al (2014) conducted their research in a New York prison and the study by Chambers (2009) was based in a prison in Texas. The US is comparable to the UK, as they are both high-income countries (The World Bank, 2018); however, it is important to note that there are still significant differences between the countries, including culture, education, language and healthcare. Consideration should also be given to the differing legal status of the fetus. In the UK the fetus has no legal rights until birth (Birthrights, 2017), whereas in the US a fetus has certain levels of protection at differing stages throughout pregnancy, depending on the state of residence (Guttmacher Institute, 2019). However, there is little evidence to suggest this has any impact when women are sentenced. The third study (Rahimipour Anaraki and Boostani, 2014) was undertaken in Iran. This could be a limitation of this review due to the differences between the UK and Iran in terms of economy (The World Bank, 2018) and human rights, which may lead to differences in reasons for imprisonment (Amnesty International, 2019). Despite this, women's experiences of motherhood and maternal wellbeing are still significant throughout the world; therefore, comparing the outcomes of the studies between the different countries could result in a more comprehensive understanding of women's experiences (Rees, 2011).
Discussion
Three key themes emerged from this review and will be the focus of this discussion: ‘motherhood produces motivation for change’; ‘low re-offending rates’; and ‘staying together: maternal and child wellbeing’.
Motherhood produces motivation for change
This is a common theme that appeared in all three studies. Goshin et al (2014) commented that simply being a mother might not be enough to make imprisoned women change, but that experiencing motherhood in a secure and supportive environment such as an MBU gave women the motivation they needed to change their behaviour for the benefit of their child. Rahimipour Anaraki and Boostani (2014) found that women wished for a different future for their child and were willing to do everything they could to provide this: specifically, distancing themselves from a criminal identity. This suggests that being able to raise their child within the prison's secure environment motivated women to change their lives for the better. This was also found by Chambers (2009), who focused on the separation of mothers and babies shortly after birth. All women who participated believed that the separation was temporary and all were planning to be reunited with their babies:
‘I just want to get out there and do the right thing, and be a mother to my child.’
This indicates that, regardless of the situation these mothers are in, having young children was a motivation for change. Sleed et al (2013) suggested that a mother's neurological attachment mechanism was particularly open to change in the first year after having a baby, making this the prime time for mother and baby bonding. Edge (2006) found that children were able to form secure attachments with their imprisoned mothers, so that if this high-risk group of women were able to access support, secure relationships could develop. However, no follow-up study has reported how many participants were reunited with or still cared for their children, which would give this study more validity. It would be easy to overlook the fact that these women may have reduced exposure to influences such as drugs, alcohol and abusive relationships while they are imprisoned, which subsequently makes caring for their children much more difficult once released (Sleed et al, 2013).
Low re-offending rates
This theme is closely linked to the first, due to women wanting to provide a better future for their children. Goshin et al (2014) found that re-offending rates were lower among women were released from an MBU (14% of 139 women), compared to women released from the general prison population (30%). However, without providing the total population of women in prison, of which this 30% is part, it could be argued that this is not statistically relevant (Petrie and Sabin, 2013). Chambers (2009) advises that allowing women to reside with their children in an MBU not only led to lower re-offending rates, but also decreased fighting among female inmates. Low re-offending rates could be the result of mothers forming close attachments with their child during their time in the MBU, where they are able to experience motherhood without external influences.
Although low re-offending rates were not directly mentioned by Rahimipour Anaraki and Boostani (2014), the study did suggest that women wanted to distance themselves from crime. Further research has suggested that re-offending rates can also be lowered when other interventions are in place instead of custodial sentences, especially those less than 12 months (Ministry of Justice, 2011; Scottish Government, 2015). Community-based projects, for example, offer women support to stabilise their lives and enable them to feel motivated to change (Scottish Government, 2015).
Staying together: maternal and child wellbeing
As the two previous themes have outlined, it is evident the child can provide the mother with motivation to change their criminal past. Comparing Chambers (2009) to Rahimipour Anaraki and Boostani (2014) shows that the child can also help the mother overcome feelings of loneliness, depression and anxiety. Chambers (2009) found that when women were separated from their babies they felt anxious, depressed and lonely, and their coping mechanism was to tell themselves the separation was temporary. In contrast, the women in the Iranian study (Rahimipour Anaraki and Boostani, 2014) reported that having their children with them not only saved them from these feelings, but also helped them ignore the stark environment of the prison. This suggests that children could provide emotional support to the women.
It is equally important not to overlook the developmental wellbeing of the child. Although it is advised that children should stay with the mother to allow secure attachments to develop (O'Keeffe and Dixon, 2015), separation may be in the best interests of some children, due to a mother's complex history. In cases of separation, the mother should be involved in the decision of where the child is placed (North, 2013). Allen (2011) suggests that earlier interventions lead to better outcomes for children, as a baby's brain development can be significantly affected without positive nurturing. Research shows that secure attachments can also be established with a primary caregiver who is not the biological mother (Bowlby, 1969). As a result, it may be decided that some children have a better chance if removed from complex situations (Ward et al, 2012).
A further important aspect to be considered is the environment of the MBU: Rahimipour Anaraki and Boostani (2014) suggested that children in their study were exposed to harsh environments where they had limited physical activity and access to sunlight, and were exposed to unfriendly behaviour from other inmates. However, this study was undertaken in Iran, so the MBU environment could be very different to the UK.
Recommendations for practice and research
This literature review has highlighted that keeping mothers and babies together in a prison environment is beneficial for the mothers; however, this needs to be counterbalanced with the best interests for the baby. Women should be provided with the appropriate advice and supported to access an MBU in a timely manner if there is one available, although this decision should not be to the detriment of the child. The decision for a child to reside with the mother in a prison environment should only occur when the child's emotional and developmental needs can be met.
There is a lack of research concerning the effects that an MBU might have on a child's development. Further longitudinal studies should therefore be undertaken to assess long-term outcomes, although a follow-up study could prove difficult to implement, because of the nature of the participants involved.
Standardised midwifery care should be provided in prisons across the UK, and prisons that do not offer midwifery care can learn from those that do. Kennedy et al (2016) advise that clinics should be provided by specialised midwives to normalise antenatal and postnatal care for this group of women, enabling them to make their own informed decisions in turn.
A further suggestion would be to introduce more community-based sentencing. Research has indicated that women who received support from community centres were less likely to reoffend (Ministry of Justice 2015). This would also allow mothers to stay in the family unit, therefore reducing separation rates.
More UK-based research should also be undertaken, to address the lack of studies on this issue in the UK.
Conclusion
This review suggests that women who give birth in prison or have young children residing with them are able to build secure attachments during their pregnancies and/or in the postnatal period. This drives their motivation for behaviour change.
Evidence suggests that regular midwifery care, as well as easy-to-access MBUs that cater for the needs of both women and children would reduce re-offending rates and have positive benefits for both women in prison and their children.