In January 2022, the Prisons and Probation Ombudsman (2022) published a report into the shocking death of a baby girl, Brooke, at Her Majesty's Prison Styal, a women's prison, in 2020. While the report makes detailed recommendations for improvements, it reaches the surprising conclusion that ‘given the exceptional nature of the event, it was not possible to form a single, overall judgement on the equivalence of [her mother's] care’. That is a difficult position to agree with, and raises more questions than it answers. The principle of equivalence needs further exploration in light of this case, and in terms of the implications for other pregnant women and babies still in prison.
The government and NHS's commitment to equivalence of care is set out as ‘the aim of ensuring that people detained in prisons in England are afforded provision of and access to appropriate services or treatment… and that this is considered to be at least consistent in range and quality (availability, accessibility and acceptability) with that available to the wider community, in order to achieve equitable health outcomes and to reduce health inequalities between people in prison and in the wider community’ (National Prison Healthcare Board, 2019).
In a BBC Newsnight (2021) interview, Baby Brooke's mother, Louise, spoke about her experience giving birth in prison. Louise had her drink spiked and, unknowingly, was raped. As she was a lesbian, she thought she could not be pregnant when she entered prison, and discounted the idea throughout her pregnancy. She went into labour in her cell and by 5pm was complaining of vaginal bleeding and excruciating pain. The senior prison officer who attended her called the healthcare department three times and each time, the nurse on duty declined to visit Louise, and did not check her records or prescribe pain relief. At 9:06pm Louise gave birth to Brooke in a prison toilet. The baby was delivered breech and was blue and unresponsive. The guards radioed for an ambulance but the radio system went down, so there was a delay in calling the ambulance, and in prioritising the response.
The consultant obstetrician involved said that if Louise had been taken to hospital earlier in the day, they would have identified the baby was in the breech position and provided expert help with the delivery. Assuming Brooke was alive during the delivery, the outcome ‘would have been very different’ (Prisons and Probation Ombudsman, 2022).
Was Louise and Brooke's care equivalent in terms of access to and provision of appropriate services and treatment? Whether or not the pregnancy was known about, the response to Louise's presentation on the day/night of birth was, by the standards above, worse than what she would have experienced in the community. Louise had to rely on a prison officer relaying her medical need to a healthcare professional, rather than being able to speak directly to a nurse or phone an ambulance herself. The barriers arising from poor practice and a system that struggles to support prisoners' basic health (Health and Social Care Committee, 2018), that privileges security over safety, meant prompt and appropriate care, including basic pain relief, was denied to her on multiple occasions.
Were Louise and Brooke's outcomes equitable? This was at least the third baby to die in custody in England since 2017 (Devlin and Taylor, 2019). One in 10 women who give birth during their time in custody deliver their baby in the prison or on the way to the hospital (Ministry of Justice, 2021). Poor care and the risks created by the prison system seem to exacerbate rather than improve the already poor outcomes associated with existing health inequalities. Women in prison are twice as likely to give birth to a premature baby that needs special care and five times more likely to have a stillbirth (Mothers and Babies: Reducing Risk through Audit and Confidential Enquiries, 2019; Murray and Summers, 2021).
So what is the implication for pregnant women and babies who remain in custody as a result of remand, sentence or recall? The prison and healthcare services must respond in detail to the individual and systemic failings highlighted in both the Prisons and Probation Ombudsman (2022) report, and the report into the death of ‘Baby A’ in Her Majesty's Prison Bronzefield in 2019 (Prisons and Probation Ombudsman, 2021). NHS Health and Justice are responsible for delivering healthcare in custody and must also speak honestly and openly about the challenges the prison environment creates for equivalence of care, and acknowledge that the intention to provide equivalence and equity does not necessarily mean it is being provided in practice. Birth Companions has experience of working with perinatal women in prison for over 25 years, and this experience leads those working for the charity to believe this is simply not possible: the barriers are too significant.
As a society, we cannot go on believing that the prison system will ever be a safe or appropriate place for pregnancy or birth. The logical response to the evidence must be a clear and conscious decision to avoid the imprisonment of pregnant women in all but the most exceptional circumstances. The Ministry of Justice and Her Majesty's Prison and Probation Service must work closely with the Sentencing Council, Her Majesty's Courts and Tribunals Service, the Magistrates' Association and others to ensure pregnant women do not enter a system unable to protect their health and the health of their babies.