Breastfeeding in Correctional Settings (2023)
Breastfeeding has well-established physical and psychological benefits for newborns and birth parents and enhances long-term bonding. Continued and ample milk supply relies heavily on being able to continue to express breast milk frequently, 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.
Endorsed by the American College of Obstetricians and Gynecologists (ACOG), June 2023, and should be construed as ACOG clinical guidance.
The National Commission on Correctional Health Care supports and recommends making accommodations for nursing individuals in custody, including at short-stay facilities, that will enable them to maintain their breast milk supply and, when feasible, to directly breastfeed their infants. Wherever possible and not precluded by security concerns, correctional facilities that house pregnant and postpartum individuals should devise systems to enable them to express breast milk for their infants and to breastfeed them directly.
The following practices are ways to support this objective:
- Allow immediately postpartum individuals to breastfeed their infants in the hospital, ensuring that they are not separated from their infants (unless medically indicated) prior to hospital discharge and that they have access to lactation support services.
- Screen women on entry to determine if they have given birth within the past 2 years and whether they are lactating.
- Counsel pregnant individuals on the benefits and nutritional needs of breastfeeding and inform them of the systems and supports in place at the facility.
- Provide accommodations to express breast milk, since regular breastfeeding on infant demand is rarely feasible for individuals 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.
- Support frequent visiting arrangements that allow direct contact between infants and birth parents, for breastfeeding and non-breastfeeding birth parents.
- Develop an arrangement for lactation specialists to provide support to individuals in custody when needed.
- Ensure appropriate supplies and timely access to a clinician to address potential postpartum breast issues for lactating and non-lactating individuals, such as breast engorgement, blocked ducts, or mastitis.
- Provide breastfeeding individuals with a special diet with appropriate caloric, fluid, calcium, protein, and vitamin D intake. Prenatal vitamins offer a convenient way to provide essential nutrients that may be missing.
- Advocate for alternatives to separating postpartum individuals from their infants, to promote the multigenerational health benefits of breastfeeding and infant bonding.
- Partner with community programs that facilitate continuation of breastfeeding/lactation and/or cohabitation with newborn or infant.
- Establish systems to track frequency of postpartum and lactating individuals in custody to enable quality improvement.
Adopted by the National Commission on Correctional Health Care Board of Directors
November 5, 2017; revised April 2018; revised March 2023
The majority of incarcerated women are of reproductive age. Some 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 individuals 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 individuals who want to provide their infants with breast milk. This includes initiation of breastfeeding for those who give birth in custody and continuation of breastfeeding for lactating individuals who enter custody.
Breastfeeding and breast milk have many short-term and long-term benefits for both the infant and the birth parent. The American Academy of Pediatrics (AAP) and the American College of Obstetricians (ACOG) and Gynecologists recommend exclusive breastfeeding for the first 6 months of life, except in individuals with medical or physical conditions that prohibit breastfeeding, introduction of other foods along with breast milk. The AAP supports continued breastfeeding until two years or beyond (American Academy of Pediatrics, 2022). Human milk contains important antimicrobial and anti-inflammatory substances that promote immune system development in the infant. Meta-analyses have confirmed that, compared to infants fed commercial formula, breastfed infants have fewer incidents of lower respiratory tract infections, ear infections, asthma, severe diarrhea, necrotizing enterocolitis, sudden infant death syndrome, infant mortality, allergic disease, celiac disease, obesity, diabetes, childhood leukemia, and lymphoma (Agency for Healthcare Research and Quality, 2007; American Academy of Pediatrics, 2022). There are well-documented disparities in breastfeeding rates in the U.S., with lower rates among Black individuals and individuals with low incomes, reflecting systemic racism and implicit bias in promoting and supporting lactation (American Academy of Pediatrics, 2022). These groups also have disproportionately higher incarceration rates, and lack of ability to breastfeed in correctional settings may contribute to these broader disparities in breastfeeding rates. Supporting lactation in correctional settings can thus promote equity in maternal-child health.
Acceptance of the medical and social importance of breastfeeding has become more widespread. 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 each time the employee needs to express milk for a nursing child for 1 year after the child’s birth. 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 incarcerated individuals who wish to breastfeed.
For the postpartum individual, improved health outcomes include less postpartum blood loss, less postpartum depression, and improved return to pre-pregnancy weight. (American College of Obstetricians and Gynecologists, 2021a). Breastfeeding is also protective against later development of breast and ovarian cancer, cardiovascular disease, type 2 diabetes, and other conditions (ibid). Psychological benefits include improved bonding between birth parent and child, which is particularly important when the birth parent is incarcerated (ibid).
Whether or not they are breastfeeding, postpartum individuals 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 (American College of Obstetricians and Gynecologists, 2021b).
There are very few contraindications to breastfeeding. Though many individuals in custody have substance use disorders, breastfeeding is safe and encouraged for postpartum individuals with opioid use disorder who are in treatment with methadone or buprenorphine, as there are benefits to their infants. While tetrahydrocannabinol (THC), the active substance in marijuana, appears to be transferred into breast milk, the infant effects of exposure to THC are not known. The AAP thus discourage marijuana use during lactation (American Academy of Pediatrics, 2018). However, breastfeeding is discouraged among individuals who are actively using illicit substances. Breastfeeding is also safe for individuals with hepatitis C (unless there are cracked nipples or other potential for blood exposure) but is not recommended for HIV-positive individuals (American Academy of Pediatrics, 2022). If mastitis is diagnosed, breastfeeding and milk expression should continue as this is an adjunct to treatment. Although most common medications are safe with breastfeeding, individuals should consult with their providers; detailed information on the safety of medications while breastfeeding is available from the Drugs and Lactation Database (LactMed) from the National Library of Medicine. While smoking is not a contraindication to breastfeeding, it can reduce milk supply. In addition, exposure to tobacco smoke and residue is harmful to children.
Proper nutrition is essential for breastfeeding individuals. They should receive a well-balanced diet with additional calories, calcium, vitamin D supplementation, prenatal vitamins, no more than three cups of caffeinated beverage per day, and increased fluid intake.
Facilitating Breastfeeding in Custody
When an incarcerated individual gives birth, they should be afforded the same abilities to bond with their infants in the hospital immediately postpartum as non-incarcerated patients. Likewise, they should have access to lactation support services while in the hospital if they choose to breastfeed. Research has shown that it is feasible for correctional facilities to support lactation; one study of a sample of state prisons and large jails reported that half of the prisons and 83% of the jails had policies supporting lactation, either through pumping or direct breastfeeding (Asiodu, 2021). Correctional facilities can enable postpartum individuals 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 individuals 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 mother-infant care programs where newborns reside with their birth parents, in the facility enabling full breastfeeding, and other systems have created policies prioritizing pregnant and postpartum individuals for community-based alternatives. Some facilities create systems so individuals 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 individuals 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 individuals 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, individuals should be able to pump or nurse frequently. The frequency varies from person to person depending on breast storage capacity, how recently postpartum they are, and other factors, but it can be as often as every 2-3 hours, especially immediately postpartum. Correctional facilities should thus have systems in place to enable people to express milk at the frequency they need to maintain their supply. The California Breastfeeding Coalition has developed a comprehensive toolkit, including model policies and checklists, for correctional facilities to implement lactation support programs.
American Academy of Pediatrics.
2018. Ryan SA, Ammerman SD, O’Connor ME; COMMITTEE ON SUBSTANCE USE AND PREVENTION; SECTION ON BREASTFEEDING. Marijuana Use During Pregnancy and Breastfeeding: Implications for Neonatal and Childhood Outcomes. Pediatrics;142(3):e20181889. doi: 10.1542/peds.2018-1889. Erratum in: Pediatrics. 2018 Aug 27;: PMID: 30150209.
2022. Joan Younger Meek, Lawrence Noble, Section on Breastfeeding; Policy Statement: Breastfeeding and the Use of Human Milk. Pediatrics; 150 (1): e2022057988. 10.1542/peds.2022-057988
American College of Obstetricians and Gynecologists.
2021a. Barriers to breastfeeding: supporting initiation and continuation of breastfeeding. ACOG Committee Opinion No. 821. American College of Obstetricians and Gynecologists. Obstet Gynecol;137:e54–62.
2021b. Breastfeeding challenges. ACOG Committee Opinion No. 820. American College of Obstetricians and Gynecologists. Obstet Gynecol;137:e42–53.
Agency for Healthcare Research and Quality. 2007. Breastfeeding and maternal and infant health outcomes in developed countries. Retrieved from the Agency for Healthcare Research and Quality Archived EPC Evidence Reports, https://archive.ahrq.gov/clinic/tp/brfouttp.htm. Retrieved October 4, 2022.
Asiodu IV, Beal L, Sufrin C. 2021. Breastfeeding in Incarcerated Settings in the United States: A National Survey of Frequency and Policies. Breastfeed Med;16(9):710-716. doi: 10.1089/bfm.2020.0410. PMID: 33835854; PMCID: PMC8563451.
California Breastfeeding Coalition. 2021 SUPPORTING LACTATION IN JAILS: Implementing a Model Policy to Meet California Penal Code § 4002.5. http://californiabreastfeeding.org/wp-content/uploads/2021/10/cbc-supporting-lactation-in-jails-DRAFT-5. Retrieved October 4, 2022
National Library of Medicine. Drugs and Lactation Database (LactMed).
https://www.ncbi.nlm.nih.gov/books/NBK501922/. Accessed October 4, 2022