Source: https://www.hhrjournal.org/2014/09/health-rights-in-the-balance-the-case-against-perinatal-shackling-of-women-behind-bars/
Timestamp: 2019-04-21 01:07:14+00:00

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In 1994, Women Prisoners of District of Columbia Department of Corrections v. District of Columbia first upheld a challenge to perinatal shackling of pregnant inmates.1 The widespread practice did not become more broadly recognized until 1999, when Amnesty International released the report Not part of my sentence: Violations of the human rights of women in custody.2 A second Amnesty International report, released in 2001 and entitled Abuse of women in custody: Sexual misconduct and shackling of pregnant women removed any lingering doubts as to the legality of the practice.3 Herein we review the current statutory, regulatory, legal, and medical framework undergirding the use of restraints on pregnant inmates and explore potential avenues of redress and relief to this challenge.
Until relatively recently (2000), individual wardens and jailers had the authority to impose perinatal restraints, given the absence of federal or state statutes. However, on January 1, 2000, Illinois broke the mold: the state legislature amended the Unified Code of Corrections to prohibit perinatal shackling during hospital transport and delivery.23 The statute mandated that “when a pregnant female prisoner is brought to a hospital…for the purpose of delivering her baby, no handcuffs, shackles, or restraints of any kind may be used. Under no circumstances may leg irons or shackles or waist shackles be used on any pregnant female prisoner who is in labor.”23 By mid-2013, 17 other states had followed suit (Arizona, California, Colorado, Delaware, Florida, Hawaii, Idaho, Louisiana, Nevada, New Mexico, New York, Pennsylvania, Rhode Island, Texas, Vermont, Washington, and West Virginia).
Federal legislative and regulatory initiatives soon followed. On April 9, 2008, President George W. Bush signed the Second Chance Act of 2007 into law, thereupon requiring that all federal correctional facilities document, report, and justify on security grounds the use of physical restraints on pregnant inmates before, during, and after labor and delivery.24 The law further mandated that the “Attorney General shall submit to Congress a report on the practices and policies of agencies within the Department of Justice relating to the use of physical restraints on pregnant female prisoners during pregnancy, labor, delivery of a child, or post-delivery recuperation.”25 Properly implemented, data collection could prove central to the enforcement of the policies in question. As written, the law does not apply to detainees of US Immigration and Customs Enforcement (ICE), which reports to the Department of Homeland Security.
Collectively, these new state and federal measures represent significant progress during the last decade. Still, the benefits apply only to one-third of the nation’s women inmates. Relief for the remaining two-thirds depends on the enactment of relevant statutes by the 31 states and the District of Columbia now lacking such legislation. Until that occurs, a confusing patchwork of state and local administrative policies—written and unwritten—will prevail.
Documented legal challenges to perinatal shackling have been emblematic of the indispensable role of litigation in the defense of human rights. Common to the majority of these cases has been the reliance on the Eighth Amendment to the United States Constitution, a provision that prohibits “cruel and unusual punishment” and that is informed by contemporary standards of decency. The standards for evaluating Eighth Amendment claims have been defined by the United States Supreme Court in Farmer v. Brennan.32 For example, the standard of “deliberate indifference to serious medical needs” is most frequently applied to medical claims. In a closely watched recent case involving a class of prisoners presenting serious medical claims in Brown v. Plata, the United States Supreme Court acknowledged “deliberate indifference to serious medical needs” as the governing standard but also applied a standard of “deliberate indifference to a substantial risk of serious harm.”33 Both standards accord deference to the clinician who evaluates “serious medical need” or “serious harm,” as demonstrated in court cases that challenge perinatal shackling.
Lacking controlling authority in the courts of sovereign nations, international human right instruments must not be construed as an extension of national legal constructs. Instead, conventions and treaties are best viewed as international bellwethers of collectively accepted standards and norms. Considered in this light, international consensus can in fact exert significant—if indirect—effect on the policies and laws of member nations worldwide. Similar, if more muffled, conclusions apply to foreign laws.
Careful consideration of the medical impact of perinatal shackling reveals a multiplicity of potential risks. The antepartum application of leg irons to mothers-to-be may cause imbalance while walking and thus increase proneness to falls.63 In that context, concurrent handcuffing may prevent a woman from breaking a fall and avoiding injury. Intrapartum shackling poses additional challenges. Preventing walking during the first stage of labor may deny the woman the benefits of labor acceleration and discomfort alleviation.64 Preventing walking during the postpartum phase may enhance the risk of deep vein thrombosis and its life-threatening embolic complications.65 In addition, restricting maternal repositioning precludes relief from aortocaval compression in the face of fetal distress or maternal hypotension.66 Maternal immobilization in the supine position also compromises the administration of epidural anesthesia. Perhaps most importantly, constrained maternal positioning undermines delivery in cases of cephalopelvic disproportion (CPD) or shoulder dystocia.67 Shackling throughout the four stages of labor may also impede the rapid transition to an emergency cesarean section if required.
In support of the aforementioned concerns, many national and international medical organizations have gone on record to oppose perinatal shackling. The American Congress of Obstetrics and Gynecology (ACOG), a leading association of over 50,000 providers concerned with women’s health, was first to register its disapproval, in 2007. ACOG noted: “Physical restraints have interfered with the ability of physicians to safely practice medicine by reducing their ability to assess and evaluate the physical condition of the mother and the fetus.”68 Also in 2007, the World Health Organization (WHO) stated: “There must be a complete bar on the use of shackling during labor.”69 In 2009, the American Correctional Health Services Association (ACHSA)70 noted that it “supports banning the use of leg irons/shackles and restraints for pregnant women during labor and delivery and immediately after they have given birth.” As recently as 2010, the American Medical Association (AMA), the largest association of physicians in the US, unanimously adopted Resolution 203 (Shackling of Pregnant Women in Labor) to prohibit shackling before, during, and after delivery.71 Also in 2010, the Board of Directors of the National Commission on Correctional Health (NCCHC), the accrediting agency of correctional health services, adopted a position statement on the matter of perinatal shackling.72 Finally, note is made of the recently issued Position Statements of the Association of Women’s Health, Obstetric & Neonatal Nursing (AWHONN) and of the American College of Nurse Midwives (ACNM).73 Weighing in on the challenge of perinatal shackling, both organizations went on record to all but ban the practice.
As is broadly appreciated, the passage of a statute, while necessary, is not sufficient to ensure its implementation. State-legislated bans on perinatal shackling are not exempt from this perennial challenge. Examples abound. The State of Illinois, the first to ban perinatal shackling, has recently signed into law an amending bill, 55 Ill. Comp. Stat. 5/3-15003.6 (2012), designed to clarify and strengthen its own 12-year-old statute.78 Backed by an advocacy consortium headed by the American Civil Liberties Union (ACLU) and the Chicago Legal Advocacy for Incarcerated Mothers (CLAIM), HB 1958 was introduced to address alleged ongoing violations of the original if imperfect law. Examples of relevant (successful) litigation include but are not limited to Zaborowski v. Dart, which raises a novel Fourteenth Amendment substantive due process claim.79 Similar concerns have been raised in Texas. A recent ACLU review of the six largest jails in Texas “brought into sharp focus the uneven implementation of the Shackling Ban and the Pregnant Inmate Care Standards.”80 More recently, California, prompted in large measure by slow implementation of a narrowly crafted statute, signed AB 2530 into law, thereby extending an existing peripartum shackling ban to cover the entire duration of pregnancy.81 Similar issues may well arise in many, if not all, of the other states in which a shackling ban statute is currently in effect. Such ongoing efforts may well be inevitable if sustained lasting changes of current practices are to be realized.
At the time of writing, additional statutory relief in the matter of perinatal shackling is not likely to occur at the federal level. A newly legislated stand-alone federal ban on perinatal shackling is deemed unlikely in the face of restrictions presently imposed by the Second Chance Act of 2007 and recent revisions of USMS, BOP, and ICE policies. Whether or not a potential federal initiative might ultimately be incorporated into long overdue correctional reform legislation remains uncertain and cannot be ruled out. Given present-day priorities, it appears unlikely that national correctional reform will rise to the top of the congressional legislative agenda anytime soon.
The prospect of prosecutorial relief at the federal level, one enabled by the Civil Rights of Institutionalized Persons Act of 1980 (CRIPA), is viewed as equally unlikely.82 Designed, in part, to protect the rights of inmates in state or local correctional facilities, the law is enforced by the Special Litigation Section of the US Department of Justice (DOJ) Civil Rights Division. Arguing violation of CRIPA, the Attorney General could, in principle, bring systemic challenges to state practices wherein perinatal shackling is perpetuated. Such prosecution would likely rest on the argument that the practice constitutes deliberate indifference to a serious medical need or is a failure to protect from a substantial risk of serious harm in violation of a pregnant inmate’s Eighth Amendment right not to be subjected to cruel and inhumane punishment. The feasibility of CRIPA-driven prosecution by the DOJ notwithstanding, the paucity of precedent in the course of the last 30 years raises significant doubts as to the materialization of this possibility.
Going forward, efforts to roll back perinatal shackling will likely rely on its moral, medical, and legal vulnerability.88 Incompliant with international instruments such as CAT and ICCPR, and likely the Standard Minimum Rules for the Treatment of Prisoners, the UN has repeatedly rebuked the practice.89 Similar concerns have been raised by failure to comply with standards of medical care set forth by leading national and international health organizations such as ACOG, WHO, ACHSA, AMA, NCCHC, AWHONN, ACNM, and APHA.
Above and beyond formal considerations, perinatal shackling must also be evaluated by its impact on a woman’s birth experience. Indeed, by its very nature, the practice of perinatal shackling runs counter to the expectation of birth with dignity. Instead, descriptors such as demeaning, humiliating, and traumatizing have been promulgated. If history is any guide, the collective thrust of dedicated advocacy, the strength of its argument, the broad national and international support, and the growing momentum, bode well for ongoing progress toward a restraint-free pregnancy in the correctional setting.
Brett Dignam, MA, JD, is Professor of Law at Columbia Law School, Columbia University, New York, NY, USA.
Eli Y. Adashi, MD, MS, is Professor of Medical Science at The Warren Alpert Medical School, Brown University, Providence, RI, USA.
Please address correspondence to Eli Y. Adashi. Email: Eli_Adashi@brown.edu.
Women Prisoners of the Dist. of Columbia Dep’t of Corr. v. District of Columbia, 877 F.Supp. 634 (D.D.C. 1994) vacated in part, modified in part, 899 F. Supp. 659 (D.D.C. 1995).
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