Supporting Mothers in Jail - No Barriers to Breastfeeding While Incarcerated

State: CA Type: Model Practice Year: 2019

Sutter County is a great place to live, work and visit. We are located in the north valley of California. Our rural community is embedded in rich agriculture where locally grown foods are as abundant as the wildlife. Centrally located from many popular destinations (a one hour drive north of Sacramento, the state capitol, a two hour drive from the Pacific Ocean and the world famous Sierra Nevada mountains), our area provides a quiet place away from the freeways and high rises of a big city. Sutter County is a farming community where John Deere tractors harvest rice in the fall and peach and prune trees bloom in the spring. Products grown here are exported throughout the world. The area hosts Pacific Flyway migrating geese, ducks and blue herons, who rest in the wildlife sanctuaries during the winter months. Sutter County is home to approximately 100,000 people, making it the 37th largest of California's 58 counties. The racial makeup of Sutter County was 61.0% White, 2.0% African American, 1.4% Native American, 14.4% Asian (good number of the Asian population is Indian and from the countries of India, Afghanistan and Pakistan), 0.3% Pacific Islander, 15.3% from other races, and 5.6% from two or more races. Children account for over 32.7% of the population. The poverty rate is 17.5%, a little less than the California state average of 19%. Sutter County's unemployment rate in May 2018 was 6.9%, slightly above the state rate of 4.2% and the U.S. average rate of 4-3.5% this year (2018). Also, the percentage of children identified as homeless in Sutter County has increased over time. Overall, these economic markers indicate that families living in Sutter County are at a disadvantage and at risk for poor health. The Sutter County LHD is a member of the Tricounties Breastfeeding Alliance (TCBA), which represents the three main counties in the California central valley north of Sacramento (Colusa, Sutter and Yuba). The breastfeeding rates in our area are some of the lowest in the state of California. Out of 49 counties, Sutter County has consistently ranked in the bottom five counties each and every year. The one delivering hospital in the three county region, Fremont Hospital (which is not Baby Friendly©), is ranked in the bottom 15 of lowest-scoring hospitals for breastfeeding initiation and the only one in the bottom fifteen in the northern part of the state. Our counties can, and must, improve its low breastfeeding initiation rates. The TCBA (of which Sutter County is a member) is under the umbrella of the California Breastfeeding Coalition (CBC), a grassroots partnership of community breastfeeding coalitions and other public and private associations. There are over 40 plus local coalitions and partnering associations in our state who support the CBC's mission: to improve the health and well-being of Californians by working collaboratively to protect, promote, and support breastfeeding. The CBC's vision is "no barriers to breastfeeding". To accomplish their mission, the CBC works to create and strengthen collaborative relationships among state and local organizations, such as the TCBA, LHDs, government agencies, hospitals and health care providers, employers and community-based breastfeeding support organizations throughout California. The aim of these collaborative efforts is to remove ALL barriers to breastfeeding in California. Since 2011, the annual Hospital Breastfeeding Fact Sheet & Reports”, published by the California WIC Association, the UCDavis Lactation Center, and the California Breastfeeding Association highlights the breastfeeding initiation rates in California hospitals by county. Sutter County falls near the very bottom. To address the low breastfeeding rates in the tricounty area, the TriCounties Breastfeeding Alliance has campaigned for a full-time Lactation Consultant (IBCLC) to be stationed in the post-partum unit at Fremont Hospital. A part-time IBCLC was hired in 2017. In addition, the TCBA has hosted two successful breastfeeding conferences, which were attended by over 100 hundred medical staff and providers in 2017 and 120 in 2018. Last year, one of our local FQHC's, Ampla Health, received funding from the WIC program in California, to hire a Regional Breastfeeding Liaison (RBL) to champion and facilitate breastfeeding promotion and support in our area. With all the efforts our county and coalition have accomplished, a subset of marginal mothers who have been routinely disregarded in breastfeeding support and discussions are incarcerated women. Since 1970, the number of women incarcerated ationwide has increased significantly, from 8,000 to over 110,000, an increase of 700%. Small counties, such as Sutter, Yuba and Colusa counties, have seen the greatest increase. About 80 percent of women in jails are single-parent mothers and are often incarcerated for nonviolent offenses. Many of these women have children under five. It is estimated that approximately 2,000 women in the U.S. serving time in prison or jail give birth each year. These women are usually taken to a local hospital to give birth and return to jail or prison without their baby. A small number of mothers are able to spend all or part of their sentence in a prison nursery if one is available. As of May 2013, only nine states have prison nurseries: New York,Nebraska, Washingto, Ohio, Indiana, South Dakota, Illinois, West Virginia, and Wyoming. Though a jail sentence is often less than prison sentence, some jails can house an inmate up to a year. A pregnant incarcerated mother in jail has even fewer options as there are no known jail nurseries. For a mother who returns to jail after she has given birth, her baby is placed with a relative or caregiver or enters foster care. This limits the bonding time a baby has with his mother and breastfeeding often ceases. Studies have shown keeping mother and baby together after delivery for extended periods of time is beneficial for the couplet. According to a 2015 study by Columbia University's School of Nursing, children who spent one to eighteen months in a prison nursery program were less likely to be anxious, depressed or withdrawn compared to babies separated from their mothers at birth. Prison nurseries, though limited in number, may be an option for some incarcerated women. However, for jail sentencing, a nursery is not an option as none are available in our tricounty area (Colusa, Sutter and Yuba county). For mothers of infants who are serving jail time, breastfeeding almost always is discontinued. The goal of the practice was to offer an option for incarcerated mothers at the Sutter County jail so that they could provide breastmilk to their infant. The Sutter County jail, located in Yuba City, California and its operations are governed by Title 15, "Minimum Standards for Local Detention Facilities” and is rated as a Type IV facility. Persons can be sentenced to the Sutter County Jail for up to one year. Currently, Sutter County Jail has 352 rated beds, 194 beds in the main jail and 158 beds in the minimum facility with an average inmate population of 250 in a given month. A recent incident at the Sutter County jail prompted the development of the proposed practice. Though not a frequent issue in the jail, due to the circumstances and the incarcerated mother's desire to provide breastmilk for her less than a week old baby, the issue initiated a collaborative assessment and team approach to address and support the difficult situation, a first for the jail staff. The pregnant mother had been booked at the jail with an undetermined length of stay. At the time of her expected due date, she was taken to the local hospital and delivered a healthy baby girl, who was placed with the family after the mother returned to the correctional facility. At the time, there were no protocols or policies in place for the mother to express her milk to prevent complications and it was the mother's desire to offer her breastmilk to the newborn. The jail health staff contacted the local public health department office and the WIC program for guidance to assist the new mom. A pump was provided by WIC and mom pumped 6-7 times each day. The jail nursing staff kept the pumped breastmilk cold with a small ice chest and freezer packs as there was no access to a refrigerator. The family came daily to the jail to pick up the breastmilk and feed to her newborn. As there were no existing protocols for the process, the Public Health Officer was contacted. A policy and procedures were hastily prepared using the guidelines from the American Academy of Pediatrics (AAP) for separation of mom and baby, a breastmilk pumping schedule, and storage and transfer of her milk to her family. The jail nursing staff, Health Officer, WIC director and lactation consultant formed a team to support the concerns, pragmatic issues and management of the mom, baby and family dynamics. The mom continued to pump her milk with a WIC provided electric breastpump for 3 months and her baby was exclusively fed her milk up until mom decided to discontinue. The mother was release one year later after her trial had concluded. This unusual and complicated case initiated a permanent adoption of three new jail protocols Communication of a patient's health needs", Lactation Accommodation and Support”, and Jail Medical Services Commitment for Transfer of Breastmilk” at the Sutter County Jail. At the time, no other jail facility had implemented similar formal policies that we knew of. The overall goal of the practice was to allow incarcerated women at the Sutter County Jail to provide breastmilk for their infant or child. The American Academy of Pediatrics recommends breastfeeding for the first 6 months of life. In addition, the Healthy People 2020 guidelines focus on increasing the number of breastfed infants in the US. The policy and procedures initiated at the Sutter County jail are a permanent change and carried over when the jail medical clinic management recently privatized. Sutter County is a small rural community and the total jail population for each month out of the year may only number a few hundred. The number of pregnant and/or breastfeeding women incarcerated in our jail may be a handful or less a year. However, the local breastfeeding coalition (TCBA), Sutter County Public Health and WIC has shared the innovative policies with other agencies, correctional facilities and stakeholders. The president of the TCBA coalition presented the case study and policy development at one international (International Lactation Consultant Association Conference) and two state summits (California Breastfeeding Coalition Summit and New Mexico Breastfeeding Conference). These conferences are attended by several hundred medical and lactation professionals. The comments and direct feedback was incarcerated mothers are often forgotten why shouldn't they be allowed to pump and save their milk” and how can we make this happen in our community?” One sheriff of a local county stated the mother is in jail for the crime we should not make the baby suffer for the wrongdoing she committed.” The president of the TCBA participates in a statewide workgroup that has convened to address the issue of lactation accommodation in correctional institutions. In 2017, the state of California legislation submitted a bill proposal (AB 2507) titled County jails: infant and toddler breast milk feeding policy.” The bill would require, on or before January 1, 2020, a county sheriff or the administrator of a county jail to develop and implement an infant and toddler breast milk feeding policy based on currently accepted best practices for lactating inmates detained in or sentenced to a county jail. In September 2018, the California legislation passed AB2507 and the bill was signed into law by the Governor of California. The grassroots work at the local and state level has garnered national attention from the United State Breastfeeding Committee and last month, a webinar was scheduled by the USBC to gather information and support concerning lactation accommodation in correctional facilities. Over 30 emails were received from across the nation within the first day of posting the webinar with comments such as I want to be involved. I don't have experience in this area, but would love to know more” and I would like to learn more. We have mixed support in our jails.” What began as a local and grassroots effort to ensure one mom was given the choice and support to offer her breastmilk to her baby has grown exponentially. Local correctional centers are adopting similar policies, and discussions have been organized statewide and nationally.
The public health issue this practice addresses is low breastfeeding rates in the marginalized population of incarcerated mothers, specifically mothers housed in city or county jails. State and federal correctional facilities occasionally provide prison nurseries as an option for some mothers, however those are quite limited. There are no known jail nurseries. The target population varies locally, depending on the size of the community and the local jail itself. Sutter County is a small rural community and the jail houses approximately 250 inmates each month, and up to 1/3 may be women. Over the course of a year, a handful of those women may be pregnant or have young children at home. In larger communities, such as San Francisco or Los Angeles, the female population can be a higher. For example, the total female jail population for the U.S. in 2017 was just under 90,000. Of those women, at any given time, thousands may pregnant or be a parent of a young child. Women's incarceration rate has grown at twice the pace of men's in recent decades, and has disproportionately been located in county jails. For example, ICE and U.S. Marshals contract with local jails to hold roughly 5,000 women. Most incarcerated women are of reproductive age and the majority have children. Correctional facilities are often ill-equipped to address women's medical, physical and emotional needs during pregnancy, according to Dr. Carol Sufrin, who provided medical care for women in the San Francisco jail from 2013-2016. She is also the author of the recently published book "Jailcare: Finding the Safety Net for Women Behind Bars" - a tough, but poignant review of the care of incarcerated women. Prior to the case study in the Sutter County Jail, there were no accommodations for a mother to provide pumped breastmilk for her baby. The Sutter County policy was quite possibly one of the first formal jail lactation accommodation policies in California, if not the nation. It is a unique example of adapting to the needs of a specific population which, in turn, supports the needs of the individual or dyad. In this situation, the mother and the baby's best health was the ultimate goal.
The overarching goal of the practice was to ensure incarcerated mothers would be provided the means to pump their breastmilk and that milk would be transfered to the family or caretaker and fed to the baby.  The county jail nurse manager contacted the county Public Health Officer of the LHD to determine a plan of action as there were no current policy and procedures in place addressing the situation.  The Public Health Officer contacted the Maternal Child and Adolescent Program's Director as well as the Women, Infants and Children Program (WIC) to determine availability of breastpumps (manual and/or electric), pumping regimen and approved protocols for storage, handling, and transfer of milk (per American Academy of Pediatrics guidelines).  The LHD team facilitated the development and adoption of the policy and procedures.  The WIC program would provide a hand pump for the immediate need, an electric pump and a personal kit for the incarcerated mother (case situation) to use for an extended time period.   A regular pumping schedule was outlined that fell within the confines of correctional parameters and a system was established for the family to retrieve the breastmilk from the jail.  The manual breastpump and electric pump kit provided for this situation was obtained from the local WIC program. The manual pumps typically cost $20.  An electric pump kit around $30. Part of the new policy included a section on future procurement of both manual and electric pump kits - funded as any other health or hygenic paraphernalia ordered by jail purchasing of supplies.  For this case, the mulituser-electric pump was returned to WIC.  Eventually, the Sutter County Jail Medical Office and Sutter County WIC were able to coordinate a permanent pump transfer and offered two multi-user electric pumps for the jail to keep as part of its inventory . This was a win-win situation, as sometimes, once mom has completed her jail time, she will re-enroll into the WIC program and has an established milk supply and can easily transition to a WIC pump.  The multi-user electric pump costs around $300 - a one time purchase.  Depending on the jail size, 2-3 pumps would be sufficient.  Manual pumps are less expensive and applicable for short-term use (a few days).  For longer sentences, an electric pump would be recommended.  Most jail facilities would question a pump brought from home, therefore a jail provided pump would be the most viable option.  Start up costs would total approximately one thousand dollars for each correctional facility with recurring (yearly) costs less than $200-$300 to replace manual pumps or electric pump kits as needed.  A nominal cost could be incurred for breastmilk storage bags, which run $10-$20 for a supply of 100. 
The desired outcome was achieved in several ways. The process (development, approval and implementation) of a policy and procedure that had not existed until this special situation presented itself. Historically, from discussions with other LHD and correctional facilities, mothers were not generally supported nor encouraged to pump their breastmilk while serving a jail sentence. Development of the policy allows the option and/or choice for mothers to continue if they wish to do so. Implementing the policy had both short- and long-term outcome results. In the long-term, the health status and well-being of infants fed their mothers milk improves and meets the goal of increasing the number of infants fed breastmilk (Healthy People 2020) as well as the vision of the California Breastfeeding Coaltion - "no barriers to breastfeeding". A short-term outcome was to increase, through the development of a policy and procedure change, the awareness and knowledge of correctional jail staff of lactation issues and accommodation for mothers who are incarcerated. Through the process of developing the new policy, many jail staff, both in the medical office and regular sheriff department deputies were consulted how to best adapt the new procedures. At an after-action follow-up interview with the jail nurse manager, she commented "supporting this mom and infant under these extenuating circumstances was team effort and has been a hightlight of my work here." Since the policies have been in place, the management of the Sutter County Jail medical office has been transfered to WellPath, a national organization that includes lactation accommodation as part of its policies. The original policy has been shared with other interested correctional facilities as requested, including the state of New Mexico. In 2018, the TCBA and the California Breastfeeding Coalition supported a state proposed legislation, AB2507, titled "County jails: infant and toddler breast milk feeding policy" - which was passed and signed into law by the governor. The new law will require, in part county, a sheriff or the administrator of a county jail to develop and implement an infant and toddler breast milk feeding policy for lactating inmates detained in or sentenced to a county jail that is based on currently accepted best practices.
Policy development often requires several stages of planning and approval. In the situation that arose at Sutter County LHD, there was no current policy to address lactation accommodation for incarcerated women. The specific incident mentioned in the summary of the application prompted the jail medical staff and County Health Officer to take appropriate and expedited action to ensure the mother could continue to provide breastmilk to her baby under the unfortunate circumstances. Due to that occurence, the jail medical office, along with the support and input of the sheriff, Health Officer, WIC Director, and Lactation Consultant, a workable policy and procedures were effected. The collaboration of the many stakeholders was invaluable. The status of prior issues (pregnant and delivering incarcerated mothers in the Sutter County jail) is unknown as there had been no communication between the staff and the LHD. Now, the parties who would be involved have a formal process to address supporting a mothers choice to offer breastmilk to her infant. An official cost/benefit analysis was not conducted as the situation presented was limited. However, larger correctional facilities could conduct studies and research on the number of incarcerated women who decide to provide breastmilk to their infant. Summarizing the circumstances that now exist in correctional communities with a high population of women is certainly warranted and conducting such research would lead to a better understanding of the problem and solutions. There is more work to do. In a recent (September 2018) publication from the ACLU titled "You miss so much when you are gone - The lasting harm of jailing mothers before trial in Oklahoma", describes the perils of mothers who are serving jail time and the resulting overwhelming debt and loss of child custody. The report, over 120 pages in length, addresses the obstacles families face if a mother is required to spend time in jail. The last page of the report devoted only a paragraph to health care services in correctional facilities and reads: "Prisons and jails should provide necessary health care services for incarcerated people free of charge, and the standard of care in detention should at least equal what is generally available in the community. Places of detention should also ensure the provision of all necessary hygiene supplies and prenatal and postpartum care and treatment." Expansion and clarification through local, state and national written and well-planned jail policies and procedures should be the next step to ensure incarcerated mothers can, if they desire, to pump their breastmilk and that milk be available to fees her baby. There are many references to support this vital movement: California legislation AB 2507 Jail Care - Carolyn Sufrin Nevada Department of Corrections Administrative Regulation #657(Women's Prison) Breast Pumping Program (2014) National Commission On Correctional Healthcare (revised 2018) - Position Statement - Breastfeeding in Correctional Settings Overlooked: Women in Jails in an Era of Reform (2016) - Vera Institute of Justice American College of Obstetricians and Gynecologists - Committee Opinion #511 - Health Care for Pregnant and Postpartum Incarcerated Women and Adolescent Females (2016) Journal of Law and Health - Pregnant Women Inmates: Evaluating their rights and identifying opportunities for improvements in their treatment (2004-05). Kelly Parker Thank you, Tina Lavy, WIC Specialist and Lactation Consultant
Colleague in my LHD