Breastfeeding in Correctional Settings (2018)
Breastfeeding has well-established physical and psychological benefits for newborns and mothers, and enhances long-term bonding. A woman’s breast milk supply relies heavily on being able to continue to produce milk, either through direct feeding or expressing milk. Although the logistical constraints of correctional settings pose challenges for breastfeeding, there are many ways to make breastfeeding possible. The National Commission on Correctional Health Care supports and recommends making accommodations for nursing women in custody, including at short-stay facilities, that will enable them to maintain their breast milk supply.
Endorsed by the American College of Obstetricians and Gynecologists (ACOG), October 2018, and should be construed as ACOG clinical guidance.
Acceptance of the medical and social importance of breastfeeding has become more widespread, and the Fair Labor Standards Act (29 U.S. Code 207) now requires employers in community workplaces to provide reasonable break time and clean, private space (excluding a bathroom) for an employee to express breast milk for her nursing child for 1 year after the child’s birth each time the employee needs to express milk. These laws also apply to employees working in correctional facilities. This accepted community and legal standard for employees highlights the importance of making accommodations for postpartum inmates who wish to breastfeed.
This position statement addresses the unique issues surrounding breastfeeding for postpartum inmates in correctional settings.
The majority of incarcerated women are of reproductive age. Some women enter jails, prisons, and juvenile facilities already pregnant and then give birth while in custody, and others have recently given birth and are breastfeeding their infants. While postpartum women represent a small proportion of the incarcerated population, they and their newborns have unique needs that the correctional facility should address. One of those needs is accommodating breastfeeding for postpartum women who want to provide their infants with breast milk.
Breastfeeding and breast milk have many short-term and long-term benefits for both the infant and the mother. The American Academy of Pediatrics and the American College of Obstetricians and Gynecologists recommend exclusive breastfeeding for the first 6 months of life, except in women with medical or physical conditions that prohibit breastfeeding, then introduction of other foods along with breast milk until at least 12 months (American Academy of Pediatrics, 2012). The Agency for Healthcare Research and Quality conducted a comprehensive analysis of scientific literature that concluded that, compared to infants fed commercial formula, breastfed infants have fewer incidents of respiratory tract infections, ear infections, GI tract infections, necrotizing enterocolitis, sudden infant death syndrome, infant mortality, allergic disease, celiac disease, obesity, diabetes, childhood leukemia, and lymphoma (Breastfeeding and Maternal and Infant Health Outcomes, 2007).
For the mothers, improved health outcomes include less postpartum blood loss, less postpartum depression, and greater postpartum weight loss (American College of Obstetricians and Gynecologists [ACOG], 2013). Breastfeeding is also protective against later development of breast and ovarian cancer, cardiovascular disease, diabetes, and other conditions (ACOG, 2013). Psychological benefits include improved bonding between mother and child, which is particularly important when the mother is incarcerated (ACOG, 2013).
Whether or not they are breastfeeding, postpartum women may experience several breast-related medical issues that correctional health staff must be prepared to address. For instance, pain from breast engorgement, blocked milk ducts, and mastitis may require frequent breast milk expression as part of medical care.
There are very few contraindications to breastfeeding. Many women in custody have substance use disorders. Breastfeeding is safe and encouraged for women who are taking methadone or buprenorphine as there are benefits to their infants. However, breastfeeding is discouraged among women who are actively using illicit substances. Breastfeeding is also safe for women with hepatitis C, but is not recommended for HIV-positive women (American Academy of Pediatrics, 2013). Most common medications are safe with breastfeeding, although women should consult with their providers. While smoking is not a contraindication to breastfeeding, it can reduce a mother’s milk supply. In addition, exposure to tobacco smoke is harmful to children.
Proper nutrition is essential for breastfeeding mothers. They should receive a well-balanced diet with additional calories, no more than three caffeinated beverages a day, increased fluid intake, and supplementation to ensure appropriate intake of vitamins and minerals, including calcium and Vitamin D.
FACILITATING BREASTFEEDING IN CUSTODY
Correctional facilities can enable postpartum women to provide breast milk for their infants in numerous ways, all of which require collaboration among medical and custody staff, and, in some cases, social services. One way is to allow women to have contact visits with their newborns as often as possible and with appropriate privacy so that they can directly breastfeed them. Skin-to-skin contact is an important factor in breast milk supply and also is psychologically important to maintain bonding and commitment to breastfeeding. Some prisons and jails have special nursery programs where newborns reside with their mothers, enabling full breastfeeding. Some facilities create systems so women can pump and store breast milk that can later be delivered to the infant. If it is not possible to store the breast milk, at a minimum, lactating women should be allowed to pump breast milk so that they can maintain their milk supply for when they are reunited with their infants. This is especially important in short-stay facilities.
To enable pumping and storage of breast milk, facilities need to acquire the appropriate equipment, allow women to pump frequently in a private and clean space, devise protocols for appropriate handling and storage of milk, and coordinate transfer of breast milk to infant caregivers. If a woman is released and has milk in storage, it should be provided to her upon release. Because breast milk supply is highly sensitive to the frequency of expressing breast milk, women should be able to pump or nurse at least every 4 hours.
Wherever possible and not precluded by security concerns, correctional facilities that house pregnant and postpartum women should devise systems to enable postpartum women to express breast milk for their babies and to breastfeed them directly.
The following practices are ways to support this objective:
1. Screen women on entry to determine if they are postpartum and breastfeeding.
2. Counsel pregnant women on the benefits and nutritional needs of breastfeeding and inform them of the systems and supports in place at the facility.
3. Provide breastfeeding women with a special diet with appropriate caloric, fluid, calcium, and vitamin D intake. Prenatal vitamins offer a convenient way to provide essential nutrients that are often missing from correctional diets.
4. Allow immediately postpartum women to breastfeed their babies and have lactation support services from the hospital.
5. Support visiting arrangements that allow direct contact between infants and mothers.
6. Provide accommodations to express breast milk, since regular breastfeeding on infant demand is rarely feasible for women in custody. Accommodations may include providing a manual or electric breast pump and storage bags, a private place to pump on a frequent basis, a freezer, and a system for proper storage of the breast milk and, when possible, transfer to the infant.
7. Establish nursery programs or alternative programs for postpartum women that will allow the infants to stay with their mothers, making breastfeeding much easier.
8. Develop an arrangement for lactation specialist services to provide support to women who need it.
Adopted by the National Commission on Correctional Health Care Board of Directors
November 5, 2017; revised April 2018
American Academy of Pediatrics. (2012, March). Breastfeeding and the use of human milk (Policy Statement). Elk Grove Village, IL: Author. Retrieved from http://pediatrics.aappublications.org/content/129/3/e827
American Academy of Pediatrics. (2013, February). Infant feeding and transmission of human immunodeficiency virus in the United States (Policy Statement). Elk Grove Village, IL: Author. Retrieved from http://pediatrics.aappublications.org/content/131/2/391
American College of Obstetricians and Gynecologists. (2013, August). Breastfeeding in underserved women: Increasing initiation and continuation of breastfeeding (Committee Opinion No. 570, reaffirmed 2016). Retrieved from https://www.acog.org/-/media/Committee-Opinions/Committee-on-Health-Care-for-Underserved-Women/co570.pdf?dmc=1&ts=20170712T1810248505
Breastfeeding and maternal and infant health outcomes in developed countries. (2007, April). Retrieved from the Agency for Healthcare Research and Quality Archived EPC Evidence Reports, https://archive.ahrq.gov/clinic/tp/brfouttp.htm