Commentary Maternity and Birthing

Sushi and Wine for Mothers-to-Be? New Book Suggests Pregnancy Rules Are Arbitrary

Martha Kempner

A new book questions the list of rules—from skipping the bar to avoiding deli meat—that most pregnant people are given during their first prenatal visit. Emily Oster, an economist, looks at the research and suggests many rules are based on caution rather than data. But many experts question her credentials.

While she was pregnant with me, my mother was under doctor’s orders to drink one alcoholic beverage a day. It was the fall of 1972, and the fetus that would become yours truly wanted out, despite not being due for another two-and-a-half months. In order to “quiet the baby,” she was put on bed rest and told to drink. My mother says that she couldn’t stand the taste of alcohol at the time, so she masked it by having vodka in apple juice. Six weeks later—exactly one month early—I arrived, slightly pickled but with no apparent permanent damage. By the time I was pregnant, 33 years later, not only was alcohol during pregnancy demonized, but the list of things you could not eat, drink, or do for nine months was long and daunting, and the feeling that one small break of the rules could lead to a lifetime of guilt was enough to keep me in line.

A new book, however, suggests that many of these rules are based on an overabundance of caution rather than clear scientific evidence. Expecting Better: Why the Conventional Pregnancy Wisdom Is Wrong—and What You Really Need to Know was written by Emily Oster, a professor at the University of Chicago, who takes on today’s dos and don’ts of pregnancy, from avoiding deli meats to limiting caffeine intake. After carefully going through the existing research and recommendations from professional groups like the American Congress of Obstetricians and Gynecologists (ACOG), Oster provides her own conclusions for pregnant women, some of which are presented in a little box called “The Bottom Line.”

Here’s the wrinkle: Emily Oster is an economist. She has no medical or health-care background, just an understanding of statistics and a distaste for the seemingly arbitrary rules she was given during pregnancy. Many people are comparing her new book to the bestselling Freakonomics, which took an economic lens to numerous issues and suggested, among other controversial finding, that car seats for kids don’t really save lives and legalizing abortion reduced the crime rate. While some find her book to be a refreshing break from the standard pregnancy guides, which refuse to say that anything is not a risk, others think she has no business giving what appears to be medical advice.

Oster became pregnant in 2009 and says she expected to make decisions about her pregnancy the way she had been trained to do as an economist—by analyzing data. Instead, she was given a list of rules without explanation, and even when pressed her OB wouldn’t or couldn’t provide the thinking behind them. Conversations with friends revealed a lack of consistency in what doctors were saying, which further confused her. And guidebooks and websites were no help either. So Oster took matters into her own hands, pulling up the academic studies, working her way through the data, and reaching her own conclusions.

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Here are some of the rules she takes on in the book along with the bottom line she reached.

Make Mine Decaf, Please. The current rule seems to be that pregnant people should limit their caffeine intake to the equivalent of two cups of coffee a day. While this might not seem like a huge hardship (seven years ago I was told only to have one), Oster wanted to see the research that showed caffeine was harmful or potentially harmful in large doses. Many of the studies she looked at questioned whether there was a link between caffeine consumption and miscarriage early in pregnancy. Some found no link, while others did—among them a 2008 study out of California that found a 25 percent miscarriage rate in women who drank more than two cups of coffee a day versus a 13 percent miscarriage rate in women who drank less, according to the book. Though this study seems to be where the rule stems from, Oster notes that there is one issue that the researchers do not seem to take into account: nausea. Early in the book, she examines research that confirms what everyone told me during the festival of dry heaving that was my second pregnancy: Feeling sick is great. It means a healthy pregnancy. It turns out they weren’t just blowing smoke; women with greater nausea have a lower chance of miscarriage. Oster argues that there is a relationship between nausea and coffee consumption during pregnancy. If you’re fighting the urge to puke every few minutes, you are probably not stopping at Starbucks for a latte. This could mean that the group of women who are not drinking coffee were self-selected and already had a lower chance of miscarriage. Though there is no data to prove this theory, Oster notes that studies of tea and soda, which are also caffeinated (though less so) but are much gentler on the stomach, have not found the same link to miscarriage. Her bottom line on caffeine is that almost every study finds two caffeinated beverages are fine and that much of the evidence says three to four cups wouldn’t do any damage either.

Sushi, Lunch Meat, and Fish, Oh My. Like many women, Oster was surprised to see so many foods on her new list of what not to eat. Her doctor told her to avoid sushi, deli meats, soft cheeses, and smoked fish and to limit her intake of fish in general. I remember grappling with this advice at an office holiday party. The pre-paid menu offered a steak (I hadn’t yet rediscovered red meat), a pasta dish with cilantro (which I despise), and a potato-crusted salmon that sounded pretty good. The problem was I had already eaten my two portions of fish for that week—my doctor’s advice had been to eat no deep-sea fish (tuna, swordfish, tile fish, or king fish) and to limit my intake all other fish to twice a week. I ordered the pasta without sauce. Oster says I probably didn’t have to take it so far. These eating rules encompass two concerns. The first is about food-borne illnesses, which is why pregnant women are told to stay away from raw meat, cured meat, lunch meat, and raw fish. Oster’s examination of the evidence basically says sushi, like raw eggs in a Caesar salad, is OK—you might get sick, but you won’t hurt your baby. Lunch meats, however, especially turkey, are probably worth avoiding because of the possibility of listeria, which has been found to cause miscarriage, preterm birth, and stillbirth in between 10 and 50 percent of pregnant women who become infected. Unfortunately, she also points out that recent outbreaks of listeria have been traced to celery, sprouts, and cantaloupe, and that in real life it’s hard to avoid completely. The other dangerous food-borne illness is toxoplasmosis, which comes from undercooked meats, dried and cured meats (like prosciutto), and unwashed vegetables. She advises washing raw veggies and avoiding raw and cured meats. (Later in the book, she debunks the idea that changing cat litter is risky for toxoplasmosis but does suggest that lots of gardening may increase exposure). The fish issue is about mercury and Omega-3 fatty acids. Mercury is bad for a developing brain (it’s been found to lower IQ), but Omega-3s are good (they’ve been found to raise IQ). Fish have both. The rule about limiting fish intake to twice a week is based on finding a balance between the two. Oster agrees this is important but thinks the answer lies in eating the right fish—those that are high in Omega-3s and low in mercury. In the book, she provides a chart, which divides fish choices into quadrants; canned tuna, grouper, and king mackerel are the worst, because they are high in mercury and low in Omega-3s, while catfish, pollock, sardines, and cod are the best.

You’re Not Really Eating for Two. One of the lowest points in my first pregnancy was when I met my OB’s partner for the very first time. (You’re supposed to rotate because you never know who is going to be on call when you go into labor.) Before even introducing herself, she looked at what the nurse wrote down and said, “How on earth did you gain seven pounds in four weeks?” I desperately wanted to lash out, “I’m pregnant, lady!” But instead I shrugged and sunk into the table with shame. A lot has been made about the idea of weight gain during pregnancy. Some research focuses on what is healthy for the pregnant person and some focuses on what is healthy for the fetus. Oster’s bottom line here seems very much based in common sense and actually ends with: “[C]hill out.” On the issue of the pregnant person’s weight, she says simply that what goes on must come off, and you know better than anyone else whether that will be hard or easy for you. As for the child, there is little evidence linking mother’s weight gain to the child’s weight later in life—so the issue is birth weight. As she puts it, in general the more weight you gain, the bigger your child will be at birth and vice versa. Babies with very high and very low birth weights can have health issues. She thinks it’s more worrisome to gain too little weight. But, mostly, she thinks we should all stop freaking out about how much weight we do or do not gain during pregnancy.

Oster goes on to address prenatal testing, what over-the-counter and prescription drugs are acceptable, epidurals during labor, and the benefits and risks of bed rest (she thinks it’s unadvisable in most cases). Her most controversial finding, however, has to do with alcohol consumption.

While nobody today would recommend a daily drink to prevent premature labor, there is debate about whether any amount of alcohol is OK at any point during pregnancy. As Oster explains, ethics prevents scientists from doing any kind of randomized controlled study on pregnant people. You can’t, for example, take a room full of similar women at similar stages of pregnancy and divide them into groups where one group binge drinks, one drinks a glass a day, and the other drinks none, and then compare their pregnancy outcomes. Instead you have to rely on pregnant women to report their drinking habits and compare those who do drink with those who don’t. The problem with this approach is that these women have other differences that can’t be ignored. Oster points to one well-cited study that found light drinking during pregnancy causes aggressive behavior in children. The problem with this study, however, is that the women who drank were also much more likely to use cocaine.

Though most of the advice for pregnant people ends with the phrase “No amount of alcohol has been proven safe,” Oster found this frustrating and not helpful when trying to decide whether to have a glass of wine or two. So again, she turned to the scientific research. The overwhelming evidence, she says, shows that light drinking is fine. To that end, her bottom lines include that women should be comfortable with one to two drinks a week in the first trimester and up to a drink a day in the second and third trimesters. She does point out that speed matters and that seven drinks a week does not mean that it’s OK to have them all at once.

This advice has drawn the ire of many in the medical community and those who have been affected by fetal alcohol syndrome (FAS). Dr. Todd Ochs of Ravenswood Pediatrics of Chicago explained to the Chicago Tribune that any alcohol that is not processed by the woman’s liver travels through the placenta into the fetus’ bloodstream. He added, “If she is a slow metabolizer, the fetal brain is bathed in a toxin. How can that be good … why would a mother do something to put her baby at risk?” A comment on an article Oster wrote for The Atlantic echoed this sentiment:

I am the foster-adoptive mother of two beautiful girls who are on the fetal alcohol spectrum, one with FAS and the other with FAE [fetal alcohol exposure]. I am also a researcher in educational psychology and special education, so I am quite familiar with the FAS literature. While I agree with Oster that the literature, by and large, does not support the contention that modest alcohol consumption during pregnancy is likely to promote FASDs or other disorders, as a mother of two girls on the fetal alcohol spectrum, I speak with authority when I say that encouraging women to indulge in alcohol during pregnancy simply isn’t worth the risk.

Others take their disapproval of Oster further, saying that she simply has no business giving out what seems an awful lot like medical advice. For her article in the Daily Beast, which is critical of Oster’s advice, Jacoba Urist spoke with a number of medical professionals. One said that she can’t imagine a doctor ever trying to evaluate economic data and give policy suggestions on housing or the financial sector. Though Urist admits Oster is no Jenny McCarthy, she believes her approach is similar to the one that The View host used when writing her book and concluding that vaccines caused her son’s autism. Urist focused on Oster’s suggestion that mothers-to-be dive into the research themselves and concludes that “telling parents with no scientific training to do it yourself can have dangerous consequences.”

When I read Oster’s book, I focused not on the suggestion to find my own information—perhaps because I am not pregnant and never plan to be again—but instead on what she found in her statistical analysis of the data. I find data, and the way it can be used to support different points of view, fascinating. And I found her explanation of it well-written and refreshingly easy to understand. I gave up on pregnancy guides by my second month of pregnancy, because I found they were either difficult to follow, condescending, or panic-inducing (and some were all three). Going to the Internet for information was even more of a crapshoot; half the time I ended up with the opinion of one parent who knew less than me. In fact, a few weeks ago, when I wrote about a new prenatal test for Rewire, I scoured the Internet for information. So much of what I found was confusing and poorly explained, and the one nugget I really needed was buried under a lot of repetitive information. I told my editor that I had decided I needed to rewrite the Internet. All of it.

I definitely would have found Oster’s book helpful in writing that article and do wish it had been around during my pregnancies. That said, I’m not sure how much I would have relied on her advice to guide my actual behavior. Much of her frustration came, at least by my read of it, from having an unhelpful OB who didn’t answer her questions. While Oster said that her OB would not explain to her why amniocentesis was recommended only after age 35, my OB told me exactly why: That’s the age at which the risk of having a baby with Down syndrome becomes greater than the risk of having a miscarriage from an amnio. She also told me that the miscarriage risk from amnios included those that happened with inexperienced doctors and rural hospitals with outdated equipment. The rates at the practice I would be going to were much better. And during my very first visit, my doctor said I could eat sushi if I wanted to, told me to keep my appointment with my colorist (hair dye is often cited as a no-no), and assured me that a glass of wine now and then wasn’t such a big deal.

Now that I think of it, maybe if Professor Oster had gone to see my doctor—with her sensible advice and willingness to share the data behind it instead of whoever she did see—there would be no book.

Analysis Abortion

‘Pro-Life’ Pence Transfers Money Intended for Vulnerable Households to Anti-Choice Crisis Pregnancy Centers

Jenn Stanley

Donald Trump's running mate has said that "life is winning in Indiana"—and the biggest winner is probably a chain of crisis pregnancy centers that landed a $3.5 million contract in funds originally intended for poor Hoosiers.

Much has been made of Republican Gov. Mike Pence’s record on LGBTQ issues. In 2000, when he was running for U.S. representative, Pence wrote that “Congress should oppose any effort to recognize homosexual’s [sic] as a ‘discreet and insular minority’ [sic] entitled to the protection of anti-discrimination laws similar to those extended to women and ethnic minorities.” He also said that funds meant to help people living with HIV or AIDS should no longer be given to organizations that provide HIV prevention services because they “celebrate and encourage” homosexual activity. Instead, he proposed redirecting those funds to anti-LGBTQ “conversion therapy” programs, which have been widely discredited by the medical community as being ineffective and dangerous.

Under Pence, ideology has replaced evidence in many areas of public life. In fact, Republican presidential nominee Donald Trump has just hired a running mate who, in the past year, has reallocated millions of dollars in public funds intended to provide food and health care for needy families to anti-choice crisis pregnancy centers.

Gov. Pence, who declined multiple requests for an interview with Rewire, has been outspoken about his anti-choice agenda. Currently, Indiana law requires people seeking abortions to receive in-person “counseling” and written information from a physician or other health-care provider 18 hours before the abortion begins. And thanks, in part, to other restrictive laws making it more difficult for clinics to operate, there are currently six abortion providers in Indiana, and none in the northern part of the state. Only four of Indiana’s 92 counties have an abortion provider. All this means that many people in need of abortion care are forced to take significant time off work, arrange child care, and possibly pay for a place to stay overnight in order to obtain it.

This environment is why a contract quietly signed by Pence last fall with the crisis pregnancy center umbrella organization Real Alternatives is so potentially dangerous for Indiana residents seeking abortion: State-subsidized crisis pregnancy centers not only don’t provide abortion but seek to persuade people out of seeking abortion, thus limiting their options.

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“Indiana is committed to the health, safety, and wellbeing [sic] of Hoosier families, women, and children,” reads the first line of the contract between the Indiana State Department of Health and Real Alternatives. The contract, which began on October 1, 2015, allocates $3.5 million over the course of a year for Real Alternatives to use to fund crisis pregnancy centers throughout the state.

Where Funding Comes From

The money for the Real Alternatives contract comes from Indiana’s Temporary Assistance for Needy Families (TANF) block grant, a federally funded, state-run program meant to support the most vulnerable households with children. The program was created by the 1996 Personal Responsibility and Work Opportunity Reconciliation Act signed by former President Bill Clinton. It changed welfare from a federal program that gave money directly to needy families to one that gave money, and a lot of flexibility with how to use it, to the states.

This TANF block grant is supposed to provide low-income families a monthly cash stipend that can be used for rent, child care, and food. But states have wide discretion over these funds: In general, they must use the money to serve families with children, but they can also fund programs meant, for example, to promote marriage. They can also make changes to the requirements for fund eligibility.

As of 2012, to be eligible for cash assistance in Indiana, a household’s maximum monthly earnings could not exceed $377, the fourth-lowest level of qualification of all 50 states, according to a report by the Congressional Research Service. Indiana’s program also has some of the lowest maximum payouts to recipients in the country.

Part of this is due to a 2011 work requirement that stripped eligibility from many families. Under the new work requirement, a parent or caretaker receiving assistance needs to be “engaged in work once the State determines the parent or caretaker is ready to engage in work,” or after 24 months of receiving benefits. The maximum time allowed federally for a family to receive assistance is 60 months.

“There was a TANF policy change effective November 2011 that required an up-front job search to be completed at the point of application before we would proceed in authorizing TANF benefits,” Jim Gavin, a spokesman for the state’s Family and Social Services Administration (FSSA), told Rewire. “Most [applicants] did not complete the required job search and thus applications were denied.”

Unspent money from the block grant can be carried over to following years. Indiana receives an annual block grant of $206,799,109, but the state hasn’t been using all of it thanks to those low payouts and strict eligibility requirements. The budget for the Real Alternatives contract comes from these carry-over funds.

According to the U.S. Department of Health and Human Services, TANF is explicitly meant to clothe and feed children, or to create programs that help prevent “non-marital childbearing,” and Indiana’s contract with Real Alternatives does neither. The contract stipulates that Real Alternatives and its subcontractors must “actively promote childbirth instead of abortion.” The funds, the contract says, cannot be used for organizations that will refer clients to abortion providers or promote contraceptives as a way to avoid unplanned pregnancies and sexually transmitted infections.

Parties involved in the contract defended it to Rewire by saying they provide material goods to expecting and new parents, but Rewire obtained documents that showed a much different reality.

Real Alternatives is an anti-choice organization run by Kevin Bagatta, a Pennsylvania lawyer who has no known professional experience with medical or mental health services. It helps open, finance, and refer clients to crisis pregnancy centers. The program started in Pennsylvania, where it received a $30 million, five-year grant to support a network of 40 subcontracting crisis pregnancy centers. Auditor General Eugene DePasquale called for an audit of the organization between June 2012 and June 2015 after hearing reports of mismanaged funds, and found $485,000 in inappropriate billing. According to the audit, Real Alternatives would not permit DHS to review how the organization used those funds. However, the Pittsburgh Post-Gazette reported in April that at least some of the money appears to have been designated for programs outside the state.

Real Alternatives also received an $800,000 contract in Michigan, which inspired Gov. Pence to fund a $1 million yearlong pilot program in northern Indiana in the fall of 2014.

“The widespread success [of the pilot program] and large demand for these services led to the statewide expansion of the program,” reads the current $3.5 million contract. It is unclear what measures the state used to define “success.”

 

“Every Other Baby … Starts With Women’s Care Center”

Real Alternatives has 18 subcontracting centers in Indiana; 15 of them are owned by Women’s Care Center, a chain of crisis pregnancy centers. According to its website, Women’s Care Center serves 25,000 women annually in 23 centers throughout Florida, Illinois, Indiana, Michigan, Minnesota, Ohio, and Wisconsin.

Women’s Care Centers in Indiana received 18 percent of their operating budget from state’s Real Alternatives program during the pilot year, October 1, 2014 through September 30, 2015, which were mostly reimbursements for counseling and classes throughout pregnancy, rather than goods and services for new parents.

In fact, instead of the dispensation of diapers and food, “the primary purpose of the [Real Alternatives] program is to provide core services consisting of information, sharing education, and counseling that promotes childbirth and assists pregnant women in their decision regarding adoption or parenting,” the most recent contract reads.

The program’s reimbursement system prioritizes these anti-choice classes and counseling sessions: The more they bill for, the more likely they are to get more funding and thus open more clinics.

“This performance driven [sic] reimbursement system rewards vendor service providers who take their program reimbursement and reinvest in their services by opening more centers and hiring more counselors to serve more women in need,” reads the contract.

Classes, which are billed as chastity classes, parenting classes, pregnancy classes, and childbirth classes, are reimbursed at $21.80 per client. Meanwhile, as per the most recent contract, counseling sessions, which are separate from the classes, are reimbursed by the state at minimum rates of $1.09 per minute.

Jenny Hunsberger, vice president of Women’s Care Center, told Rewire that half of all pregnant women in Elkhart, LaPorte, Marshall, and St. Joseph Counties, and one in four pregnant women in Allen County, are clients of their centers. To receive any material goods, such as diapers, food, and clothing, she said, all clients must receive this counseling, at no cost to them. Such counseling is billed by the minute for reimbursement.

“When every other baby born [in those counties] starts with Women’s Care Center, that’s a lot of minutes,” Hunsberger told Rewire.

Rewire was unable to verify exactly what is said in those counseling sessions, except that they are meant to encourage clients to carry their pregnancies to term and to help them decide between adoption or child rearing, according to Hunsberger. As mandated by the contract, both counseling and classes must “provide abstinence education as the best and only method of avoiding unplanned pregnancies and sexually transmitted infections.”

In the first quarter of the new contract alone, Women’s Care Center billed Real Alternatives and, in turn, the state, $239,290.97; about $150,000 of that was for counseling, according to documents obtained by Rewire. In contrast, goods like food, diapers, and other essentials for new parents made up only about 18.5 percent of Women’s Care Center’s first-quarter reimbursements.

Despite the fact that the state is paying for counseling at Women’s Care Center, Rewire was unable to find any licensing for counselors affiliated with the centers. Hunsberger told Rewire that counseling assistants and counselors complete a minimum training of 200 hours overseen by a master’s level counselor, but the counselors and assistants do not all have social work or psychology degrees. Hunsberger wrote in an email to Rewire that “a typical Women’s Care Center is staffed with one or more highly skilled counselors, MSW or equivalent.”

Rewire followed up for more information regarding what “typical” or “equivalent” meant, but Hunsberger declined to answer. A search for licenses for the known counselors at Women’s Care Center’s Indiana locations turned up nothing. The Indiana State Department of Health told Rewire that it does not monitor or regulate the staff at Real Alternatives’ subcontractors, and both Women’s Care Center and Real Alternatives were uncooperative when asked for more information regarding their counseling staff and training.

Bethany Christian Services and Heartline Pregnancy Center, Real Alternatives’ other Indiana subcontractors, billed the program $380.41 and $404.39 respectively in the first quarter. They billed only for counseling sessions, and not goods or classes.

In a 2011 interview with Philadelphia City Paper, Kevin Bagatta said that Real Alternatives counselors were not required to have a degree.

“We don’t provide medical services. We provide human services,” Bagatta told the City Paper.

There are pregnancy centers in Indiana that provide a full range of referrals for reproductive health care, including for STI testing and abortion. However, they are not eligible for reimbursement under the Real Alternatives contract because they do not maintain an anti-choice mission.

Parker Dockray is the executive director of Backline, an all-options pregnancy resource center. She told Rewire that Backline serves hundreds of Indiana residents each month, and is overwhelmed by demand for diapers and other goods, but it is ineligible for the funding because it will refer women to abortion providers if they choose not to carry a pregnancy to term.

“At a time when so many Hoosier families are struggling to make ends meet, it is irresponsible for the state to divert funds intended to support low-income women and children and give it to organizations that provide biased pregnancy counseling,” Dockray told Rewire. “We wish that Indiana would use this funding to truly support families by providing job training, child care, and other safety net services, rather than using it to promote an anti-abortion agenda.”

“Life Is Winning in Indiana”

Time and again, Bagatta and Hunsberger stressed to Rewire that their organizations do not employ deceitful tactics to get women in the door and to convince them not to have abortions. However, multiple studies have proven that crisis pregnancy centers often lie to women from the moment they search online for an abortion provider through the end of their appointments inside the center.

These studies have also shown that publicly funded crisis pregnancy centers dispense medically inaccurate information to clients. In addition to spreading lies like abortion causing infertility or breast cancer, they are known to give false hopes of miscarriages to people who are pregnant and don’t want to be. A 2015 report by NARAL Pro-Choice America found this practice to be ubiquitous in centers throughout the United States, and Rewire found that Women’s Care Center is no exception. The organization’s website says that as many as 40 percent of pregnancies end in natural miscarriage. While early pregnancy loss is common, it occurs in about 10 percent of known pregnancies, according to the American Congress of Obstetricians and Gynecologists.

Crisis pregnancy centers also tend to crop up next to abortion clinics with flashy, deceitful signs that lead many to mistakenly walk into the wrong building. Once inside, clients are encouraged not to have an abortion.

A Google search for “abortion” and “Indianapolis” turns up an ad for the Women’s Care Center as the first result. It reads: “Abortion – Indianapolis – Free Ultrasound before Abortion. Located on 86th and Georgetown. We’re Here to Help – Call Us Today: Abortion, Ultrasound, Locations, Pregnancy.”

Hunsberger denies any deceit on the part of Women’s Care Center.

“Clients who walk in the wrong door are informed that we are not the abortion clinic and that we do not provide abortions,” Hunsberger told Rewire. “Often a woman will choose to stay or return because we provide services that she feels will help her make the best decision for her, including free medical-grade pregnancy tests and ultrasounds which help determine viability and gestational age.”

Planned Parenthood of Indiana and Kentucky told Rewire that since Women’s Care Center opened on 86th and Georgetown in Indianapolis, many patients looking for its Georgetown Health Center have walked through the “wrong door.”

“We have had patients miss appointments because they went into their building and were kept there so long they missed their scheduled time,” Judi Morrison, vice president of marketing and education, told Rewire.

Sarah Bardol, director of Women’s Care Center’s Indianapolis clinic, told the Criterion Online Edition, a publication of the Archdiocese of Indianapolis, that the first day the center was open, a woman and her boyfriend did walk into the “wrong door” hoping to have an abortion.

“The staff of the new Women’s Care Center in Indianapolis, located just yards from the largest abortion provider in the state, hopes for many such ‘wrong-door’ incidents as they seek to help women choose life for their unborn babies,” reported the Criterion Online Edition.

If they submit to counseling, Hoosiers who walk into the “wrong door” and “choose life” can receive up to about $40 in goods over the course their pregnancy and the first year of that child’s life. Perhaps several years ago they may have been eligible for Temporary Assistance for Needy Families, but now with the work requirement, they may not qualify.

In a February 2016 interview with National Right to Life, one of the nation’s most prominent anti-choice groups, Gov. Pence said, “Life is winning in Indiana.” Though Pence was referring to the Real Alternatives contract, and the wave of anti-choice legislation sweeping through the state, it’s not clear what “life is winning” actually means. The state’s opioid epidemic claimed 1,172 lives in 2014, a statistically significant increase from the previous year, according to the Centers for Disease Control and Prevention. HIV infections have spread dramatically throughout the state, in part because of Pence’s unwillingness to support medically sound prevention practices. Indiana’s infant mortality rate is above the national average, and infant mortality among Black babies is even higher. And Pence has reduced access to prevention services such as those offered by Planned Parenthood through budget cuts and unnecessary regulations—while increasing spending on anti-choice crisis pregnancy centers.

Gov. Pence’s track record shows that these policies are no mistake. The medical and financial needs of his most vulnerable constituents have taken a backseat to religious ideology throughout his time in office. He has literally reallocated money for poor Hoosiers to fund anti-choice organizations. In his tenure as both a congressman and a governor, he’s proven that whether on a national or state level, he’s willing to put “pro-life” over quality-of-life for his constituents.

Analysis Maternity and Birthing

Pregnant Women Are Being Shackled in Massachusetts—Even Though It’s Been Illegal for Years

Victoria Law

According to a new report, not a single jail or prison facility in the state has written policies that are fully compliant with the law against restraining pregnant women behind bars.

Korianne Gamble was six months pregnant in November 2014 when she arrived at the Bristol County Sheriff’s Office Women’s Center, a jail in North Dartmouth, Massachusetts. Six months prior, the state had passed “An Act to Prevent Shackling and Promote Safe Pregnancies for Female Inmates.”

According to the new law, the jail should have been prohibited from using any type of restraint on Gamble during labor, and using of leg and waist restraints on her during and immediately after her pregnancy. It also guaranteed her minimum standards of pregnancy care and required—as with everyone incarcerated while in their second or third trimesters—that she be transported in the jail’s vehicles with seat belts whenever she was taken to court, medical appointments, or anywhere outside the jail.

But that wasn’t the case for Gamble. Instead, she says, when it came time for her to give birth, she was left to labor in a cell for eight hours before finally being handcuffed, placed in the back of a police cruiser without a seatbelt, and driven to a hospital, where she was shackled to the bed with a leg iron after delivering.

According to a new report, Gamble isn’t alone. Advocates have been monitoring pregnancy-related care since the law’s passage. After obtaining and analyzing the policies of the state’s prison and jail system, they found that no facility has policies that are fully compliant with the 2014 law. They issued their findings in a new report, Breaking Promises: Violations of the Massachusetts Pregnancy Standards and Anti-Shackling Lawco-authored by Marianne Bullock of the Prison Birth Project, Lauren Petit of Prisoners’ Legal Services of Massachusetts, and Rachel Roth, a reproductive-justice expert.

In addition to analyzing policies, they spoke with women who were pregnant while in custody and learned that women continue to be handcuffed during labor, restrained to the bed postpartum, and placed in full restraints—including leg irons and waist chains—after giving birth.

“The promise to respect the human rights of pregnant women in prison and jail has been broken,” the report’s authors concluded.

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Medical experts, including the American Congress of Obstetricians and Gynecologists, the American Medical Association and the American College of Nurse-Midwives, have all agreed that shackling during pregnancy is unnecessary, inhumane, and dangerous. Shackling increases the risk of falling and injury to both mother and fetus while also preventing medical staff from assessing and assisting during labor and delivery. In 2014, both the Massachusetts legislature and then-Gov. Deval Patrick (D) agreed, passing the law against it.

“The Massachusetts law is part of a national trend and is one of the most comprehensive in protecting pregnant and postpartum women from the risks of restraints,” said Roth in an interview with Rewire. “However, like most other states, the Massachusetts law doesn’t have any oversight built in. This report clearly shows the need for staff training and enforcement so that women who are incarcerated will be treated the way the legislature intended.”

Gamble learned all of this firsthand. In the month before her arrest, Gamble had undergone a cervical cerclage, in which a doctor temporarily stitches up the cervix to prevent premature labor. She had weekly visits to a gynecologist to monitor the development of her fetus. The cerclage was scheduled to be removed at 37 weeks. But then she was arrested and sent to jail.

Gamble told jail medical staff that hers was a high-risk pregnancy, that she had had a cerclage, and that her first child had been born six weeks prematurely. Still, she says she waited two months before seeing an obstetrician.

As her due date drew closer, the doctor, concerned about the lack of amniotic fluid, scheduled Gamble for an induction on Feb. 19, 2015. But, she says, jail staff cancelled her induction without telling her why.

That same evening, around 5 p.m., Gamble went into labor. Jail staff took her to the medical unit. There, according to Gamble, the jail’s nurses took her blood pressure and did a quick exam, but did not send her to the hospital. “They [the nurses] thought I was ‘acting up’ because my induction was canceled,” she told Rewire.

She was placed in a see-through cell where, as the hours progressed, her labor pains grew worse. “I kept calling to get the [correctional officers] to get the nurse,” Gamble recalled. By the time a nurse came, Gamble was bleeding. “The nurse made me pull down my pants to show her the blood—in front of a male [correctional officer]!” Gamble stated. Still, she says, no one called for an ambulance or made arrangements to drive her to the hospital.

At 1:45 in the morning, over eight hours after she first went into labor, the jail’s captain learned that Gamble was in labor. “[He] must have heard all the commotion, and he called to find out what was going on,” she said. He ordered his staff to call an ambulance and bring her to the hospital.

But instead of calling an ambulance, Gamble says jail staff handcuffed her, placed her in the back of a police cruiser without a seatbelt—in violation of the law—and drove her to Charlton Memorial Hospital. “My body was already starting to push the baby out,” she said. She recalled that the officers driving the car worried that they would have to pull over and she would give birth by the side of the road.

Gamble made it to the hospital, but just barely. Nine minutes after arriving, she gave birth: “I didn’t even make it to Labor and Delivery,” she remembered.

But her ordeal wasn’t over. Gamble’s mother, who had contacted Prisoners’ Legal Services and Prison Birth Project weeks earlier, knew that the law prohibited postpartum restraints. So did Gamble, who had received a packet in jail outlining the law and her rights from Prisoners’ Legal Services. When an officer approached her bed with a leg iron and chain, she told him that, by law, she should not be restrained and asked him to call the jail to confirm. He called, then told her that she was indeed supposed to be shackled. Gamble says she spent the night with her left leg shackled to the bed.

When the female officer working the morning shift arrived, she was outraged. “Why is she shackled to the bed?” Gamble recalled the officer demanding. “Every day in roll call they go over the fact that a pregnant woman is not to be shackled to anything after having a baby.” The officer removed the restraint, allowing Gamble to move around.

According to advocates, it’s not unusual for staff at the same jail to have different understandings of the law. For Gamble, that meant that when the shift changed, so did her ability to move. When the morning shift was over, she says, the next officer once again shackled Gamble’s leg to the bed. “I was so tired, I just went along with it,” Gamble recounted.

Two days after she had given birth, it was time for Gamble to return to the jail. Despite Massachusetts’ prohibition on leg and waist restraints for women postpartum, Gamble says she was fully shackled. That meant handcuffs around her wrists, leg irons around her ankles, a chain around her waist,g and a black box that pulled her handcuffs tightly to the waist chain. That was how she endured the 20-minute drive back to the jail.

Gamble’s jail records do not discuss restraints. According to Petit, who reviewed the records, that’s not unusual. “Because correctional officers don’t see it as out of the ordinary to [shackle], they do not record it,” she explained. “It’s not so much a misapplication of the extraordinary circumstances requirement as failure to apply it at all, whether because they don’t know or they intentionally ignore it.”

While Bristol County Sheriff’s Office Women’s Center’s policies ban shackling during labor, they currently do not prohibit restraints during postpartum recovery in the hospital or on the drive back to the jail. They also do not ban leg and waist restraints during pregnancy. Jonathan Darling, the public information officer for the Bristol County Sheriff’s Office, told Rewire that the jail is currently reviewing and updating policies to reflect the 2014 law. Meanwhile, administrators provide updates and new information about policy and law changes at its daily roll call. For staff not present during roll call, the jail makes these updates, including hospital details, available on its east post. (Roll call announcements are not available to the public.)

“Part of the problem is the difference in interpretation between us and the jurisdictions, particularly in postpartum coverage,” explained Petit to Rewire. Massachusetts has 14 county jails, but only four (and the state prison at Framingham) hold women awaiting trial. As Breaking Promises noted: “Whether or not counties incarcerate women in their jails, every county sheriff is, at minimum, responsible for driving women who were arrested in their county to court and medical appointments. Because of this responsibility, they are all required to have a written policy that spells out how employees should comply with the 2014 law’s restrictions on the use of restraints.”

Four jurisdictions, including the state Department of Correction, have policies that expressly prohibit leg and waist restraints during the postpartum period, but limit that postpartum period to the time before a woman is taken from the hospital back to the jail or prison, rather than the medical standard of six weeks following birth. Jails in 11 other counties, however, have written policies that violate the prohibition on leg and waist shackles during pregnancy, and the postpartum prohibition on restraints when being driven back to the jail or prison.

Even institutions with policies that correctly reflected the law in this regard sometimes failed to follow them: Advocates found that in some counties, women reported being restrained to the bed after giving birth in conflict with the jail’s own policies.

“When the nurse left, the officer stood up and said that since I was not confirmed to be in ‘active labor,’ she would need to restrain me and that she was sorry, but those were the rules,” one woman reported, even though the law prohibits restraining women in any stage of labor.

But shackling pregnant women during and after labor is only one part of the law that falls short. The law requires that pregnant women be provided with regular prenatal and postpartum medical care, including periodic monitoring and evaluation; a diet with the nutrients necessary to maintain a healthy pregnancy; written information about prenatal nutrition; appropriate clothing; and a postpartum screening for depression. Long waits before transporting women in labor to the hospital are another recurring complaint. So are routinely being given meals without fruits and vegetables, not receiving a postpartum obstetrician visit, and waiting long stretches for postpartum care.

That was also the case with Gamble. It was the middle of the night one week after her son’s birth when Gamble felt as if a rock was coming through her brain. That was all she remembered. One hour later, she woke to find herself back at the hospital, this time in the Critical Care Unit, where staff told her she had suffered a seizure. She later learned that her cellmate, a certified nursing assistant, immediately got help when Gamble’s seizure began. (The cell doors at the jail are not locked.)

Hospital staff told her that she had preeclampsia, a pregnancy complication characterized by high blood pressure. Postpartum preeclampsia is rare, but can occur when a woman has high blood pressure and excess protein in her urine soon after childbirth. She was prescribed medications for preeclampsia; she never had another seizure, but continued to suffer multiple headaches each day.

Dr. Carolyn Sufrin is an assistant professor of gynecology and obstetrics at Johns Hopkins Medicine. She has also provided pregnancy-related care for women at the San Francisco County Jail. “Preeclampsia is a leading cause of maternal mortality,” she told Rewire. Delayed preeclampsia, or postpartum preeclampsia, which develops within one to two weeks after labor and delivery, is a very rare condition. The patient suffering seizures as a result of the postpartum preeclampsia is even more rare.

Postpartum preeclampsia not only needs to be treated immediately, Sufrin said, but follow-up care within a week at most is urgent. If no follow-up is provided, the patient risks having uncontrolled high blood pressure, stroke, and heart failure. Another risk, though much rarer, is the development of abnormal kidney functions.

While Sufrin has never had to treat postpartum preeclampsia in a jail setting, she stated that “the protocol if someone needs obstetrical follow-up, is to give them that follow-up. Follow through. Have continuity with the hospital. Follow their instructions.”

But that didn’t happen for Gamble, who was scheduled for a two-week follow-up visit. She says she was not brought to that appointment. It was only two months later that she finally saw a doctor, shortly before she was paroled.

As they gathered stories like Gamble’s and information for their report, advocates with the Prison Birth Project and Prisoners’ Legal Services of Massachusetts met with Rep. Kay Khan (D-Newton), to bring her attention to the lack of compliance by both county jails and the state prison system. In June 2015, Khan introduced An Act to Ensure Compliance With the Anti-Shackling Law for Pregnant Incarcerated Women (Bill H 3679) to address the concerns raised by both organizations.

The act defines the postpartum period in which a woman cannot be restrained as six weeks. It also requires annual staff trainings about the law and that, if restraints are used, that the jail or prison administration report it to the Secretary of Public Safety and Security within 48 hours. To monitor compliance, the act also includes the requirement that an annual report about all use of restraints be made to the legislature; the report will be public record. Like other statutes and bills across the country, the act does not have specific penalties for noncompliance.

In December 2015, Gamble’s son was 9 months old and Gamble had been out of jail for several months. Nonetheless, both Gamble and her mother drove to Boston to testify at a Public Safety Committee hearing, urging them to pass the bill. “I am angered, appalled, and saddened that they shackled her,” Gamble’s mother told legislators. “What my daughter faced is cruel and unusual punishment. It endangered my daughter’s life, as well as her baby.”

Since then, both the Public Safety Committee and Health Care Financing Committee approved the bill. It is now before the House Committee for Bills in the Third Reading, which means it is now at the stage where it can be taken up by the House for a vote.

Though she has left the jail behind, Gamble wants to ensure that the law is followed. “Because of the pain I went through, I don’t ever want anyone to go through what I did,” she explained to Rewire. “Even though you’re in jail and you’re being punished, you still have rights. You’re a human being.”