Analysis Law and Policy

Why We May See Different Outcomes in the Wisconsin and Alabama TRAP Trials

Jessica Mason Pieklo

An unusual suggestion by the U.S. Court of Appeals for the Seventh Circuit could have significant implications for trials over admitting privileges requirements in Alabama and Wisconsin—it could be the difference between one court upholding the requirement and the other striking it.

In December of 2013, when the U.S. Court of Appeals for the Seventh Circuit upheld a temporary injunction blocking a requirement that doctors performing abortions in the state have admitting privileges at nearby hospitals, the court did an usual thing: It urged the trial court to appoint its own expert to give testimony on the need and impact of the proposed regulations. Now, with trials over admitting privileges laws coming to a close in both Wisconsin and Alabama, that request could prove to be even more significant—it could be the difference between one court upholding the requirement and the other striking it.

Normally in litigation, the parties hire expert witnesses to help explain their case to the court, and the federal rules of evidence spell out exactly how the court is to consider that testimony, and piles of case law further clarify when an expert is to be considered qualified and when they are not. Generally speaking, if some kind of scientific, technical, or other specialized knowledge will assist the court in understanding the evidence, and if a witness is qualified based on their knowledge, skill, experience, training, or education, then that witness can offer testimony—so long as that testimony is based on enough facts or data, the result of the expert using reliable principles and methods, and the expert has applied those principles and methods reliably in the case at hand.

In the lawsuits challenging the constitutionally of admitting privileges requirements in Alabama and Wisconsin, this means experts testified on the purported health and safety rationale and the impact the requirements would have on the delivery of reproductive health care to patients in the state. Butthe case for admitting privileges depends on biased junk science to confuse otherwise settled issues of medical opinion, and that is exactly what state attorneys general offered in these trials.

As reported by The Isthmus, both of the expert witnesses relied on by attorneys for the State of Wisconsin were brought into the case by discredited psychotherapist Vincent Rue. Rue is best known for coining the phrase “post-abortion syndrome,” which purports to link abortion to various mental health issues like depression. Rue first invented the condition in the early 1980s, but the condition is not recognized by either the American Psychological Association or the American Psychiatric Association.

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Rue is no stranger to serving as an expert in abortion restriction litigation and has a well-deserved reputation for biased testimony. Rue’s testimony in what would become the landmark Planned Parenthood v. Casey case was rejected because his “admitted personal opposition to abortion, even in cases of rape and incest, suggests a possible personal bias.”

As The Isthmus reported, the State of Wisconsin plans to pay Rue approximately $48,000 for his work as an expert consultant on the case and for serving as a “liaison” between the state and the experts its attorneys planned to call as witnesses to defend the law. Both witnesses, Dr. James Anderson and Dr. James Linn, testified that they became involved in the case after being contacted by the state. Anderson testified that Rue helped him “wordsmith” his expert report submitted to the court, while Linn admitted during cross examination that he was not aware Rue was discredited by the medical community.

Anderson also testified for the State of Alabama in the legal challenge to that state’s admitting privileges requirement and is also serving as an expert consultant for the state in the case.

Was this precisely the scenario the Seventh Circuit saw unfolding when it suggested the trial court in Wisconsin appoint its own expert? It seems to be. Here’s Judge Richard Posner, writing for the majority in the Seventh Circuit in the Planned Parenthood of Wisconsin v. Van Hollen opinion, making the case for an independent, court-appointed expert to testify on the need and impact of the admitting privileges requirement:

And so the district judge’s grant of the injunction must be upheld. But given the technical character of the evidence likely to figure in the trial—both evidence strictly medical and evidence statistical in character concerning the consequences both for the safety of abortions and the availability of abortion in Wisconsin-the district judge may want to reconsider appointing a neutral medical expert to testify at the trial, as authorized by Fed.R.Evid. 706(a), despite the parties’ earlier objections. Given the passions that swirl about abortion rights and their limitations there is a danger that party experts will have strong biases, clouding their judgment. They will still be allowed to testify if they survive a Daubert challenge, but a court-appointed expert may help the judge to resolve the clash of the warring party experts. And the judge may be able to procure a genuine neutral expert simply by directing the party experts to confer and agree on two or three qualified neutrals among whom the judge can choose with confidence in their competence and neutrality. If either side’s party experts stonewall in the negotiations for the compilation of the neutral list, the judge can take disciplinary action; we doubt that will be necessary.

Ultimately, Judge William Conley took the Seventh Circuit’s suggestion and appointed Dr. Serdar Bulun, chair of obstetrics and gynecology at Northwestern University’s Feinberg School of Medicine, to serve as the court’s unbiased expert on the admitting privileges law. The Milwaukee-Journal Sentinel reported that while the three experts in the case—one for the state, one for Planned Parenthood, and Bulun—did not reach agreement on the need for the admitting privileges law, they did agree that abortion is a safe procedure and is about as risky as colonoscopies and other outpatient procedures.

That may not seem like much, but in a case built entirely on the false premise that requiring abortion providers to have admitting privileges protects the safety of patients, an admission by the state that abortion is a generally safe procedure akin to a colonoscopy either means the law does unconstitutionally target abortion providers, or it’s time to start heavily regulating proctologists.

Unlike the court in Wisconsin, the court in Alabama did not appoint its own independent expert, and with a decision in both cases still pending and appeals likely regardless of the outcomes, we can’t say for certain that the presence of the court-appointed expert in the Wisconsin case made any difference in the cases’ outcomes or not. But, given the often lackadaisical method some federal courts have used in evaluating the credibility of the “evidence” offered to support anti-abortion restrictions like admitting privileges requirements, and the proliferation of junk science promoted by anti-choice advocates, Judge Posner may have offered reproductive rights and public health advocates an important opportunity to guide federal courts away from confusion intentionally induced by anti-abortion advocates and toward a more rational review of the law.

Culture & Conversation Media

TRAP Laws and the Abortion ‘Crisis’: A Conversation With Award-Winning Filmmaker Dawn Porter

Tina Vasquez

Recently, Porter spoke with Rewire about the inaccurate framing of abortion as a “moral” issue and the conditions that have created the current crisis facing providers and patients alike. Her film will air nationally on PBS’ Independent Lens Monday.

Dawn Porter’s documentary TRAPPED focuses on the targeted regulation of abortion providers (TRAP) laws designed to close clinics. But, as Porter told Rewire in a phone interview, TRAPPED is also about “normal people,” the providers and clinic staff who have been demonized due to their insistence that women should have access to abortion and their willingness to offer that basic health-care service.

Between 2010 and 2015, state legislators adopted some 288 laws regulating abortion care, subjecting providers and patients to restrictions not imposed on their counterparts in other medical specialties.

In Alabama, where most of the film takes place, abortion providers are fighting to keep their clinics open in the face of countlessand often arbitrary—regulations, including a requirement that the grass outside the facilities be a certain length and one mandating abortions be performed in far more “institutional” and expensive facilities than are medically necessary.

The U.S. Supreme Court is expected to issue a ruling this month on a Texas case regarding the constitutionality of some TRAP laws: Whole Woman’s Health v. Hellerstedt. The lawsuit challenges two provisions in HB 2: the admitting privileges requirement applied to Whole Woman’s Health in McAllen, Texas, and Reproductive Services in El Paso, Texas, as well as the requirement that every abortion clinic in the state meet the same building requirements as ambulatory surgical centers. It is within this context that Porter’s film will air nationally on PBS’ Independent Lens Monday.

Recently, the award-winning filmmaker spoke with Rewire about the Supreme Court case, the inaccurate framing of abortion as a “moral” issue, and the conditions that have created the current crisis facing providers and patients alike.

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Rewire: What has changed for the clinicians featured in TRAPPED since the documentary premiered at the Sundance Film Festival in January?

Dawn Porter: Now, in Alabama, the legislature has passed a law banning clinics within 2,000 feet of a school. There’s a lot of frustration because the clinicians abide by the laws, and then more are put in place that makes it almost impossible to operate.

Everyone has been really focused on Dalton Johnson’s clinic [the Alabama Women’s Center for Reproductive Alternatives] because the clinic he moved to was across the street from a school, but the law has also affected Gloria [Gray, the director of the West Alabama Women’s Center in Tuscaloosa, Alabama]and that’s not something a lot of us initially realized. She’s afraid this will shut her down for good. I would say this has been a very hard blow for her. I think Dalton was perhaps more prepared for it. He will fight the law.

The good news is that it’s not like either of these clinics will close tomorrow; this gets decided when they go back for relicensing at the end of the year. Right now, they’re in the middle of legal proceedings.

Of course, we’re all also awaiting the Supreme Court decision on Whole Woman’s Health. There’s a lot of uncertainty and anxiety right now, for these clinic owners in particular, but for all clinic owners [nationwide] really.

Rewire: Let’s talk about that. Later this month, the Supreme Court is expected to issue its ruling on that caseEven if the Supreme Court rules that these laws are unconstitutional, do you think the case will change the environment around reproductive rights?

DP: It really depends on how the Court writes the decision. There may be no case in which it’s more important for the Court to have a comprehensive decision. It’s a multiheaded hydra. There’s always something that can close a clinic, so it’s crucially important that this Court rules that nothing can hinder a woman’s right to choose. It’s important that this Court makes it clear that all sham laws are unconstitutional.

Rewire: We know abortion providers have been killed and clinics have been bombed. When filming, did you have safety concerns for those involved?

DP: Definitely. The people who resort to violence in their anti-choice activities areI guess the most charitable way to describe itunpredictable. I think the difficult thing is you can’t anticipate what an irrational person will do. We took the safety of everyone very seriously. With Dr. Willie Parker [one of two doctors in the entire state of Mississippi providing abortions], for example, we wouldn’t publicize if he’d be present at a screening of the film. We never discussed who would appear at a screening. It’s always in the back of your mind that there are people who feel so strongly about this they would resort to violence. Dr. Parker said he’s aware of the risks, but he can’t let them control his life.

We filmed over the course of a few years, and honestly it took me a while to even ask about safety. In one of our last interviews, I asked Dr. Parker about safety and it was a very emotional interview for both of us. Later during editing, there was the shooting at the Colorado clinic and I called him in a panic and asked if he wanted me to take our interview out of the film. He said no, adding, “I can’t let irrational terrorists control my life.” I think everybody who does this work understands what’s at risk.

Rewire: It seems Texas has become ground zero for the fight for abortion access and because of that, the struggles in states like Alabama can get lost in the shuffle. Why did you choose to focus on Alabama?

DP: I met Dr. Parker when he was working in Mississippi. The first meeting I did with him was in December 2012 and he told me that Alabama had three clinics and that no one was talking about it. He introduced me to the clinic owners and it was clear that through them, the entire story of abortion access—or the denial of itcould be told. The clinic owners were all working together; they were all trying to figure out what to do legally so they could continue operating. I thought Alabama was unexplored, but also the clinic owners were so amazing.

To tell you the truth, I tried to avoid Texas for a long time. If you follow these issues around reproductive rights closely, and I do, you can sort of feel like, “Uh, everyone knows about Texas.” But, actually, a lot of people don’t know about Texas. I had this view that everyone knew what was going on, but I realized I was very insulated in this world. I started with Texas relatively late, but decided to explore it because we were following the lawyers with the Center for Reproductive Rights and they were saying one of their cases would likely go to the Supreme Court, and Whole Woman’s Health was most likely. They, of course, were right.

When you’re making a film, you’re emerged in a world and you have to take a step back and think about what people really know, not what you think they know or assume they know.

Rewire: In TRAPPED, you spliced in footage of protests from the 1970s, which made me think about how far we’ve come since Roe v. Wade. Sometimes it feels like we’ve come very far, other times it feels like nothing has changed. Why do you think abortion is such a contentious topic?

DP: I don’t think it’s actually that contentious, to tell you the truth. I think there is a very vocal minority who are extreme. If you poll them, most Americans are pro-choice and believe in the right to abortion in at least some circumstances. Most people are not “100 percent, no abortion” all the time. People who are, are very vocal. I think this is really a matter of having people who aren’t anti-choice be vocal about their beliefs.

Abortion is not the number one social issue. It was pretty quiet for years, but we’ve seen the rise of the Tea Party and conservative Republicans heavily influencing policy. The conservative agenda has been elevated and given a larger platform.

We need to change public thinking about this. Part of that conversation is destigmatizing abortion and not couching it in a shameful way or qualifying it. Abortion is very common; many, many women have them. Three in ten U.S. women have had an abortion before the age of 45. I think that part of the work that needs to be done is around stigma and asking why are we stigmatizing this. What is the agenda around this?

Evangelicals have done a great job of making it seem like this is an issue of morality, and it’s just not. To me, honestly, it doesn’t matter if you’re pro-choice or anti-choice. Everyone is entitled to their own opinions and beliefs. I can respect different opinions, but I can’t respect someone who tries to subvert the political process. People with power and influence who tamper with the political process to impose their beliefs on other people—I really can’t respect that.

Rewire: There are a lot of entry points for conversations about abortion access. What brought you to focus on TRAP laws?

DP: People often discuss abortion in terms of morality, but that’s not what we should be talking about. The reason why these laws have been so effective is because they successfully harm the least powerful of the group they’re targeting. Who’s getting picked on, who’s suffering the most? Women of color, people who are low-income, people who don’t have health insurance. There’s something so unjust about how these laws are disproportionately affecting these populations, and that really bothered me. I’m certainly interested in abortion as a topic, but I’m also interested in politics and power and how those things take shape to hurt the most vulnerable.

Rewire: In TRAPPED, we get to see a very personal side of all the clinicians and providers. One clinician discusses having to be away from her six children all of the time because she’s always at the clinic. We get to see Dr. Willie Parker at church with his family. And it was amazing to learn that the remaining providers in Alabama are friends who regularly eat dinner together. Was it intentional to humanize providers in a way we don’t usually get to see?

DP: Absolutely. The anti-choice side has successfully painted the picture of an abortion provider as this really shady, sinister person. I spent three years embedded in these clinics, and that couldn’t be further from what I saw. These are passionate, brave people, but they’re also very normal people. They’re not superheroes or super villains. They’re just normal people. It’s not that they don’t think about what they’re doing; they’re just very resilient and courageous in a way that makes me very proud. I wanted people to see that.

Rewire: Honestly before watching TRAPPED, I never thought about the personal toll that pressure takes on providers. Dalton Johnson used his retirement funds in order to continue providing abortion care. In several scenes, we see an emotional Gloria Gray struggling with whether or not to keep fighting these laws. Do you think people generally understand what it’s costing providers—financially and emotionally—to continue operating?

DP: I don’t think a lot of us think about that. People like Dalton are saying, “I would rather cash out my retirement than give in to you people.” We should not be asking people to make that kind of sacrifice. That should not be happening.

We also don’t spend enough time thinking about or talking about all of the things that have happened to create the conditions we’re now dealing with. It’s like a perfect storm. Medical schools are not training abortion providers, and the abortion providers that are around are getting older and retiring. Of course laws keep getting passed that make it more and more difficult to run a clinic. In this kind of environment, can you really blame people for not wanting to be providers? Especially when there’s the added pressure of having to take not just your own safety into account, but the safety of your family.

Anti-choice people target the children of abortion providers. They target them at home. This is a hard job if you want to have a life. I mean that literally too—if you literally want to have your life.

This is why so few go into this field. As the number of providers in some states continues to get eliminated, the burden left on those standing is exponentially greater.

The reason why we have a crisis around abortion care is not just laws, but because we have so few physicians. There are all of these factors that have come together, and we didn’t even get to cover all of it in the documentary, including the fact that Medicaid doesn’t cover abortion [under federal law. Seventeen states, however, use state funds to cover abortion care for Medicaid recipients.] A lot of this is the result of conservative lobbying. People have to be aware of all the pressures providers are under and understand that we didn’t get to this point of crisis accidentally.

Rewire: It can feel hopeless, at least to me. What gives you hope when it comes to this unrelenting battle for reproductive rights in this country?

DP: I don’t feel hopeless at all. I feel like it’s really important to be aware and vigilant and connect these dots. I wanted to help people understand the complications and the challenges providers are up against.

These providers have done their part, and now it’s time for the rest of us to do ours. People can vote. Vote for people who prioritize providing education and medical care, rather than people who spend all of their time legislating an abortion clinic. Alabama is in a huge fiscal crisis. The education system is a mess. The Medicaid system is a mess, and the whole Alabama state legislature worked on a bill that would affect a couple of abortion clinics. Voters need to decide if that’s OK. I think this is all very hard, but it’s not at all hopeless.

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.”