Lactation Support for People Who Are Incarcerated: A Systematic Review

Breastfeeding intentions

Five studies described experiences of incarcerated women who wanted to breastfeed or express milk for their infants.^{8,13,14,28,31} One qualitative study reported findings from interviews with 20 pregnant women incarcerated in New York City jails. This cohort of women resided in one of the rare facilities that allows infants to stay with their mothers in a jail nursery for up to 1 year after birth.

Of the 20 women, 13 planned to breastfeed and an additional 3 would have decided to breastfeed if they were not HIV positive. These women spoke about seeking a new beginning in motherhood, and they saw breastfeeding as part of this plan, allowing them to carry out maternal duties and support their sense of self-worth. Women also reported feeling that their inability to use substances while in jail created a more safe and secure environment to initiate breastfeeding. Many of the study participants had jail sentences lasting <1 year in duration, facilitating the possibility of swift re-entrance into society and parenting roles outside the carceral system. ²⁸

Another study surveyed participants of a doula intervention for pregnant incarcerated women to assess breastfeeding intentions. Of the 39 women participating in this pregnancy and parenting program, 45.5% intended to breastfeed and 64.1% initiated breastfeeding. ⁸ Many of these women were unable to meet their breastfeeding intention due to the inhospitable environment and lack of support. In another case study, a mother in jail described how she wanted to breastfeed, but was not permitted to try:

I had an officer with me the whole time that I was there [in the hospital]. I was trying to get away with not having an officer there. You know, it depends on where you stand in jail, if you're bad or you're good. But I was in between. So I had an officer there with me, and they didn't leave my side … They didn't let the baby in the room with me. I don't know why. The officers told me that with other ladies they had been in the hospital with, they had let the baby in the room. They had to call me every time she needed to be fed. In the hospital, they asked me if I wanted to breastfeed. And at first I wanted to. And then I was uncomfortable. There was an officer in the room every time I went to feed the baby. So it took away the urge that I had to breastfeed. ¹³

Another case study described an incarcerated woman on methadone maintenance for previous heroin use, who wanted to breastfeed, but faced numerous barriers within the prison and hospital systems. This mother accessed support and advocacy from a perinatal home visiting agency (PHVA) to address barriers, such as being denied her legal right to maintain custody of the baby within the prison system and receiving incorrect medical advice to avoid breastfeeding while taking methadone. This mother expressed her milk for the baby daily, despite her infant being discharged from the hospital to a grandmother who resided 2 hours from the prison. ¹⁴

Another ethnographic study described an incarcerated woman in a San Francisco jail who wanted to breastfeed and expressed gratitude for the opportunity to have visits with her baby where she felt she could access her “maternal self” through activities like breastfeeding. While this mother expressed milk in the jail to maintain her supply, the baby could not successfully latch on to breastfeed during visits, and the mother opted to instead use the time with her baby to cuddle and feed formula from a bottle. The author of this study used a reproductive justice framework to describe how mass incarceration both disrupts motherhood, while at the same time promoting an idealized normative motherhood unattainable during incarceration. ³¹

Together, these studies highlight motivations to breastfeed during incarceration, including as expressions of maternal care and self-advocacy or self-worth. They also identify ways that incarceration disrupts breastfeeding through separation of dyads, logistical hurdles, stigma, and lack of support.

Reasons not to breastfeed

Two studies explored reasons why some incarcerated women did not plan to breastfeed.^28,30 Some women were concerned about their substance use or poor health and perceived that these things might affect their milk quality. Breastfeeding intentions were affected by women's perceived ability to abstain from what they considered to be contraindicated substances, such as alcohol and tobacco, an unhealthy diet, or routine medications. Women living with HIV described a strong sense of needing to protect their infants from HIV infection. Some women noted that formula feeding would facilitate the ability of family members to feed the infant during separation. ²⁸

Some women expressed concerns that breastfeeding would encourage their infants to become “too attached” to them, making forced separation and the abrupt process of weaning more emotionally difficult. ²⁸ In an ethnographic study of participants in a mother-child prison in a Bay Area City, one participant expressed fear of the connectedness associated with mothering, the degree to which her infant would depend on her for feeding, and how this dynamic might change her relationship with her infant: “That whole breastfeeding thing just didn't work for me … I didn't want some little thing attached to my boob all the time, looking at me like a cow at every meal.” ³⁰

These reasons not to breastfeed explicitly identify perceived protection of the infant as an important factor in women's infant feeding decisions, including perceived protection from undue distress during separation and protection from potential exposures. They also suggest that social stigma and internalized stigma contribute to “mother blame” attitudes in which breastfeeding poses a risk to infants, which outweighs any perceived benefit. Together, these concerns highlight potential areas for prenatal education and postnatal lactation counseling.

Pain of postpartum-newborn separation

Dealing with the painful experience of coerced separation of mothers and infants after birth was a common theme in the literature.^{19,27,28,31,35,36} Most dyads affected by incarceration are separated after birth, with the infant being discharged from the hospital to a caretaker and the mother being returned to the carceral setting. A feasibility study of a doula intervention for pregnant incarcerated women described a mother who breastfed her infant in the hospital before separation.

This study noted how the mother reported feeling “terribly sad that the baby would have to switch to formula” and that she had breastfed the baby while in the hospital “hardly putting her down at all.” The process of mother-infant separation was an “emotionally harrowing experience” for mothers and the doulas supporting them. ³⁶ Another study that included qualitative interviews with 12 incarcerated mothers from a southwest Texas prison hospital found four themes in the context of forced mother-infant separation: (1) “a love connection,” (2) “everything was great until I birthed,” (3) “feeling empty and missing a part of me,” and (4) “I don't try to think too far in advance.”

These mothers were not allowed to breastfeed, but one participant reported having breastfed her infant before separation. The experience of forced separation from the infant and the loss of a love connection developed during the pregnancy were traumatic. Mothers described coping with this painful experience by looking at pictures of their infants and focusing on the separation as temporary. ²⁷ Another pilot study of an education and psychosocial support group developed for pregnant incarcerated women identified issues of loss and grief as participants' priorities for discussion. ¹⁹

Ethnographic research from a women's jail in San Francisco described how one mother had never had the experience of going home from the hospital after birth with any of her three children. Child Protective Services (CPS) placed a police hold on the baby whose birth is described in this study, which meant the mother could not practice the Baby-Friendly Hospital Initiative (BFHI) standard of rooming-in with her newborn and could only breastfeed by being escorted to the hospital's nursery, while handcuffed. This unanticipated early separation devastated the mother, who “wailed for nearly an hour as the nurse removed her baby from her room.”

The mother was already guarded at all times, but this procedurally unnecessary hold was easy for the CPS worker to invoke given the mother's “reproduction as a black woman in the criminal legal system was already so policed, her maternal criminality already presumed.” ³¹ Any effort to provide lactation support to people who have given birth while incarcerated will need to address the immediate and longer-term harms of separating these parent-infant dyads.

Breastfeeding knowledge and desire for education

Three studies explored incarcerated women's breastfeeding knowledge and priorities for desired education and support.^19,28,33 In semistructured interviews with 20 incarcerated women at the New York City Rikers Island Jail's Rose M. Singer Center, almost all participants reported receiving breastfeeding education from family or community supports before incarceration, but reported only average ratings of breastfeeding knowledge, proficiency, and confidence. Most wanted to learn more about breastfeeding techniques, milk expression, and weaning, and many had misconceptions about how routine illnesses and substances, such as tobacco and medications, would affect their milk. ²⁸

Educational topics noted as priorities by pregnant incarcerated women as part of the development of a pilot support group included infant feeding and bonding with one's baby. ¹⁹ Another quality improvement study to improve postpartum depression screening for incarcerated women in Milwaukee described participants' relief at being screened and their description of having “felt listened to” more than at any other time in a carceral setting. One unintended benefit of this empowering patient-centered screening was that it led to four of the mothers starting a milk expression program at the carceral facility. ³³ Unifying themes from these studies include a desire for comprehensive lactation education and support and the importance of lactation in postpartum bonding and well-being.

Lactation policies

One study found that seven prisons and two jails had written lactation policies about breastfeeding or milk expression. ²⁵ Another noted that carceral officers typically follow policies set forth by their institutions. Health care providers can review relevant policies and procedures from the carceral settings and develop educational and support groups to address gaps, in some cases by directly educating carceral staff on the benefits of lactation and the needs of breastfeeding mothers.^17,19

Interventions to improve and align policies across health care and carceral facilities used tools such as resource binders, daily clinical reporting between institutions, ¹⁷ and care coordinators liaising between different units and communicating information about women's rights. ²⁹ One case study described carceral staff and the health care team using guidelines from the Office of Women's Health to develop a policy for safe expression, handling, and storage of human milk. ¹⁸

Another case study described how a group of perinatal clinicians researched recommendations for optimal perinatal care and identified legislative policies to challenge the use of shackles during labor, implement immediate postpartum skin-to-skin, and offer extended lactation support. ²³ However, one ethnographic study noted that the robust human milk pumping protocol used in one women's jail might be perceived by incarcerated birthing people to promote a particular kind of idealized motherhood that may be unattainable within the carceral system and contradictory to incarceration's violation of reproductive autonomy. ³¹

Health care and carceral linkages

While most women do not receive lactation support in carceral settings, where programs exist, they are often the result of linkages across health care and carceral workforces.^{17–20,22,29} A collaboration between health care providers and carceral center staff in Idaho led to cross-training between the two groups aligned with the American College of Obstetricians and Gynecologists (ACOG) and Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN) best practice guidelines. Mothers' support people were invited to participate in the birth, and nurses encouraged women to room-in with their newborns and actively participate in caretaking. If a woman wanted to breastfeed, she received help from a lactation consultant and was taught how to use a pump before discharge to establish and maintain a milk supply. Women were given access to unlimited infant visits at the carceral facility in a redesigned family-centric room, where women breastfeed or provide their expressed milk. ¹⁷

Another study described an agreement between a carceral facility and health care providers that directed the acquisition of pumps, education for facility employees and inmates, and provision of lactation specialists for ongoing guidance and support. Of the 17 births since the program's inception, 6 women chose to participate, and 2 were released 6 weeks after childbirth and reported planning to continue breastfeeding. One participant was able to express milk and have it delivered to the Neonatal Intensive Care Unit for the entire time her infant was hospitalized after birth. ²²

Another case study described a health care team, carceral guards, and an incarcerated woman's family working together to support the mother to express and store milk, noting that at 10 days of age, the infant was exclusively breast milk fed. ²⁰ A program developed by health care providers working in a Northeastern women's prison involved coordination with the prison warden to gain buy-in for aligning practices with evidence-based standards. As part of improvements made to prenatal care, a lactation consultant was available to meet with all women individually to discuss breastfeeding. ¹⁸

Successful programs addressed multiple steps from the BFHI framework, including improved prenatal education, staff training, lactation support, and discharge planning and coordination to identify creative logistics to overcome separation and maintain lactation. Establishing formal linkages between health care providers caring for incarcerated women at birth and staff within the prison or jail, such as the nursing and medical staff, can improve continuity of care, interinstitutional commitment, and rapport between incarcerated women and the staff who are working to address their needs.^18,19,29

Jail- or prison-based programs to enable lactation

Most incarcerated mothers are unable to reside with their infant after birth. Women in prison often serve longer sentences in locations far from their home communities, while women in jails and juvenile residential facilities typically have shorter stays in locations near their homes. While these differences create unique challenges for lactation, programs have been developed within both settings to support women to express milk and maintain their milk supply during separation from their infants so that they may breastfeed or continue to provide human milk for their infant after release.

Two studies surveyed the current landscape of programs to support onsite milk expression in carceral facilities.^25,26 A survey of 22 state prison systems and 6 county jails across the United States found that 5 prisons and 2 jails allowed women to express milk, but the milk must be discarded. Over a 6-month period at sites that allowed lactation, there were 207 women who gave birth in the prisons and an average of 8 women per month who expressed milk.

At the jails, there were 67 women who gave birth and an average of 6 women per month who expressed milk. One prison supported daily visits with the infant in the first 6 weeks, but only allowed milk expression and not direct breastfeeding. ²⁵ A survey of juvenile residential systems in three states found that all three allowed breastfeeding during newborn visitations. In addition, two sites permitted mothers to express milk and have it delivered to their infant. ²⁶

Eight articles described jail- or prison-based interventions to support incarcerated mothers to express milk.^{12,17,18,20–22,29,33} In 2004, as part of efforts to increase breastfeeding rates in Alabama, the Alabama Breastfeeding Committee (ABC) formed, partnering with the Alabama Prison Project to provide pumps to incarcerated mothers and to facilitate the shipment of frozen milk to infant caregivers. ²¹ In a Northeastern U.S. women's prison, a carceral nurse worked with the prison medical and custody staff to develop a procedure to simultaneously maintain security and safeguard women’ right to express milk. ¹⁸

As part of the implementation of gender responsive programming developed at a detention facility in Los Angeles County, a community transition unit was formed to build external partnerships to support perinatal services for incarcerated women and support continuity of care after release. As part of these partnerships, the American Civil Liberties Union of Los Angeles suggested a lactation program and worked with the command staff at the jail. They used existing lactation programs from other jurisdictions to inform their approach and developed policies for medical clearance, safe storage, and transfer of milk. The program allows infant caregivers to pick up the mother's milk once a week. The staff have found that the program has been “instrumental in allowing the women to bond with their infants, despite being in custody.” ²⁹

One study illustrated the external advocacy required to start a human milk expression program for incarcerated mothers, describing the work of the Prison Birth Project (PBP) at a regional women's jail where the doulas advocate on behalf of their incarcerated clients. While the jail facility used to give new mothers a one-size-too-small sports bra and suggest taking cold showers to reduce milk supply, the PBP helped mothers access a pump. One mother expressed milk five times a day for 6 months, sending the frozen milk to the baby's caregiver and nursing the baby at weekly visits. ¹² Another quality improvement project aimed at improving perinatal depression screening for incarcerated women led participants to feel empowered to organize to meet their own additional needs, with four women starting a jail-based milk expression program. ³³

Policies and programs that support lactation in carceral settings are rare. Where they do exist, necessary components may include the presence of a dedicated internal champion and/or the support of a committed external community-based organization.

Educational programs

Ten studies reported the availability of educational programs relevant to breastfeeding or milk expression for incarcerated mothers, health care providers, and carceral staff.^{8,12,14,17,19,22,24,25,28,29} In the survey reported by Asiodu et al, 19 prisons and 5 jails noted the availability of programs for perinatal populations, with the most common being parenting classes. ²⁵ In some communities, Lamaze Certified Childbirth Educators provide prenatal breastfeeding education to incarcerated women and doulas offer birthing and postpartum support. ²⁴ The PHVA in New York offered biweekly prenatal health and parenting education sessions using a strength-based approach.

This mother-centered education included information about mothers' legal right to maintain custody of a child within the prison system for up to 18 months and the New York State Department of Health's Breastfeeding Mother's Bill of Rights, which give mothers the right to breastfeed within 1 hour after birth, unless harmful to the infant's health. ¹⁴ Another study described a pilot education and psychosocial support group for incarcerated pregnant women, which responded to participants' desire for education on topics such as infant feeding by engaging participants in developing an informational booklet that is now distributed to all pregnant women in the facility. ¹⁹

The evaluation of gender responsive programs developed for the nation's largest women's jail found that implementation first required staff training and rapport-building with pregnant incarcerated women. A gender responsive advocate position was created to coordinate care for pregnant inmates. She was able to disseminate information on jail programming such as the lactation program, track women's needs over time, and improve communication across different jail units. ²⁹ In a partnership between the health and carceral system in Idaho, perinatal nursing staff learned about carceral facility infrastructure, while the corrections staff received childbirth education. The health system staff provided free birth and parenting classes at the carceral center as a community service for educating infant caregivers. These interinstitutional educational programs were enabled by having designated representatives from each organization for communication, visits to each facility, and a shared goal to align processes. ¹⁷

Finally, a prospective cohort study found a prenatal education program to be associated with positive breastfeeding outcomes. About 45% of participants intended to breastfeed at entry to the perinatal doula program. During one-on-one prenatal meetings with doulas, 69.2% of women discussed breastfeeding at least one time, and discussing breastfeeding was significantly associated with breastfeeding initiation, with 65% of participants breastfeeding before hospital discharge. Incorporating breastfeeding discussions into these meetings was so effective, that women who discussed breastfeeding with a doula prenatally were seven times as likely to initiate breastfeeding as women who did not. ⁸

Like the implementation of lactation programs, educational efforts were often designed and implemented by community-based nurses, childbirth educators, and other lactation professionals focused on improving care and connection for people experiencing incarceration. Some programs emerged internally, often as the result of explicit requests by pregnant and postpartum people incarcerated in the facility or following an in-depth evaluation of services available. While evaluations going beyond descriptions of the programs were rare, extant evaluation data support robust educational efforts as an essential component of ongoing lactation support during incarceration.

Prison nurseries and residential programs

Seven studies described prison nurseries and residential programs, where parent-infant dyads stay together in a carceral setting after birth.^{13–16,25,28,31} Although these programs have been shown to increase breastfeeding, ³² they are rare, serve only a limited number of incarcerated pregnant people, and do not always address mothers' infant feeding priorities.^13,14,25,31

In a survey of 22 state prison systems and 6 county jails over a 2-year period, only 3 prisons had nursery programs and only 19 of the 95 (18%) infants born to mothers at these prisons were placed with their mothers in the nurseries. One jail had a nursery program, and of the three births that occurred during the reporting time, one infant went to the nursery. ²⁵ The Rose M. Singer Center in New York City's Rikers Island offers the only jail-based nursery program in the United States, where incarcerated pregnant women receive breastfeeding education and health care services. Women are transferred to a nearby Baby-Friendly hospital for delivery, where they are provided breastfeeding counseling and allowed to room-in with the infant. Postpartum incarcerated women who are enrolled in the jail's nursery program can reside with their infants for up to 1 year. ²⁸

A prison nursery at the Nebraska Correctional Center for Women was developed for mothers who give birth while incarcerated, accommodating up to six infants. After birth, incarcerated mothers care for their infants, attend classes, and work part time at the facility. Community resources, such as La Leche League, are used to support breastfeeding. The mothers are offered donated items, including bottles and formula, and a “Sponsor a Baby” program allows individuals and community groups to provide items for mothers and babies after their release (i.e., highchairs and baby feeding utensils). ¹⁶

Another nursery program at the Indiana Women's Prison allows new mothers to live on a special unit with their infants after birth. While on this unit, the mothers take breastfeeding classes and access family therapy and Healthy Start services. These mothers can also leave the unit to attend GED, vocational, or substance use disorder (SUD) treatment programs. Other incarcerated women who meet qualifying criteria serve as nannies for the program, caring for the babies when the mother attends class or needs support, and babies are also welcome during classes for mothers. ¹⁵

One residential program for incarcerated women with histories of substance use in a large, midwestern metropolitan area housed women through pregnancy and a minimum of 4 months postpartum before discharge into the community on parole. Participants could be supported by a family member or program volunteer at birth, and then returned to the program to reside with their infants until release. The program offered on-site childcare to allow women to attend educational and therapeutic sessions, employment enhancement services, and substance abuse education. Nearly 20% of residential program participants breastfed compared with only 2.9% of mothers who remained in the prison. Despite the benefits, this program was terminated because of legislation enacted in 1998, phasing out the use of community placement and early release. ³²

Several studies discussed limitations of existing residential programs for incarcerated mothers and infants in the context of infant feeding. One case study discussed perinatal care for a woman serving a 1-year jail sentence, who received methadone treatment for previous heroin use. The mother did not feel supported to breastfeed as she had intended and was not allowed to room-in with the newborn during treatment in the hospital for neonatal opioid withdrawal syndrome (NOWS). After returning to the jail, the mother and infant were released together into a community-based residential treatment parenting program, but by this time, the mother was not breastfeeding due to the earlier lack of support. ¹³

Another ethnographic study of a Community Prisoner Mothers Program in the Bay Area described institutional practices that similarly lacked consideration of the mothers' infant feeding priorities and concerns. The program had a clear idea about what mothers needed to learn: to bond with their children. In weekly parenting class, the focus was on how mothers should put aside their own needs to hold and care for their children. The parents had no privacy, and mothers were called on to bond with their infants in a way that expressed total dedication, even where women had ambivalent feelings about caretaking activities like breastfeeding. ³⁰

Another case study described how a PHVA advocated for an incarcerated mother on methadone maintenance who wanted to breastfeed, but the prison nursery denied the mother's application because the baby was not considered a “well baby” due to treatment for methadone withdrawal at birth, against evidence-based recommendations. This mother was returned to the county jail and denied hospital visits to her baby, who remained in the neonatal intensive care unit after birth. ¹⁴ Space and funding are necessary to ensure carceral facilities adequately meet the needs of parent-infant dyads, as one study noted that New York facilities routinely deny mothers their legal right to maintain custody of infants within the prison system by claiming an inability to meet children's needs. ¹⁴

Although often heralded as the “solution” to the challenge of supporting lactation for parent-infant dyads experiencing incarceration, the effectiveness of prison/jail nursery programs is limited by availability across facilities, capacity within facilities, and structural limitations on the kinds of lactation support they provide. Nurseries and residential programs should provide services that are tailored to the unique needs and priorities of their parent-infant dyads by engaging these parents in program design and adaptation.

Medications for opioid use disorder

Five studies addressed lactation for mothers receiving medications for opioid use disorder (MOUD).^{12–14,32,34} The PBP doulas advocated for their patients who were treated with methadone during pregnancy, educating hospital staff about the value of breastfeeding, while a mother tapers off methadone in the postpartum. ¹² Similarly, family support workers in the PHVA advocated for an incarcerated mother's ability to breastfeed her infant, despite her doctors' advice to avoid breastfeeding, while on methadone maintenance therapy. PHVA staff identified research to validate the use of methadone while breastfeeding and found support from a pediatrician to educate hospital staff. ¹⁴

As mentioned above, mothers who were selected for a community-based, residential program for incarcerated women with histories of SUD had significantly higher breastfeeding initiation compared with similar mothers who remained in prison. ³² However, a mother who was released into a different residential treatment program with her infant was unable to breastfeed as a result of an inhospitable environment and lack of support at birth. ¹³

A study of infants with NOWS found that compared with those born to nonincarcerated mothers, infants born to incarcerated mothers had lower rates of human milk feeding at the time of hospital discharge. While the carceral facility described in the study provided electronic and manual pumps, a refrigerator, supplies for safe milk storage, and a means to deliver milk to the infant, the authors found that incarcerated mothers on methadone faced unique barriers to milk expression and their infants had lower rates of human milk feeding at the time of hospital discharge. In contrast with other incarcerated mothers, those using methadone had to leave their general population cells to reside in the prison medical ward so that carceral officers could monitor milk expression to avoid diversion of milk containing small amounts of methadone to other incarcerated women.

These mothers were also required to deliver their milk to the hospital themselves during supervised visits, which only occurred sporadically. ³⁴ Given the tremendous value of parental-infant contact and human milk in the management of NOWS, further study in this area is warranted.

Advocacy

Several articles urged health care providers to advocate at national, state, local, and individual levels aimed at reducing incarceration and keeping birthing people and their children in community-based alternatives.^{9–11,23,27,28,30} Preventing carceral involvement addresses the first gap relevant to lactation support for incarcerated women: the experience of forced birthing parent-infant separation after birth. Clarke and Adashi also call for the expansion of prison diversion and community drug treatment programs to keep families together in their communities, avoiding the use of jails as treatment facilities. ¹³ Alternatives to incarceration are essential to reducing the number of Black women and women of color, who are disproportionately imprisoned and burdened by maternal and infant health disparities because of structural racism.

Where no policy or practice has been implemented to enable lactation within the health care setting, individual health care providers have engaged in patient advocacy, in some cases independently and directly responding to the needs of their patients. In a survey of nurses' experiences providing perinatal care for incarcerated patients, one respondent described the lack of breastfeeding support available in the hospital, noting that she worked outside the institution to advocate for new mothers to be able to use a pump in prison: “We can give them a hand pump to keep their milk supply going. The problem is that the prison can't store the milk. Sometimes, I have volunteered to go over and get the milk, especially if the mom is going to be released in a week or two.” ³⁵

Standards for evidence-based care

Another strategy for addressing the gap in the implementation of evidence-based and dignified lactation services within carceral facilities is dissemination of national standards for postpartum health care in prisons and jails. ²⁵ Interinstitutional partnerships to create milk expression programs in jails and prisons may serve as templates for bridging standardized policy gaps.^{17,18,20–22} Many of the articles reviewed included specific recommendations for elements of evidence-based care. First, lactation services should ensure improvements in carceral infrastructure to provide space and resources for breastfeeding and milk expression, including pumps, time accommodations, and lactation support.^11,16,28

Access to doulas,^{8,11,12,14,19,36} childbirth educators,^11,24 home visiting programs, ¹⁴ lactation consultants,^17,18,22,27 and other health care providers^17,19 who can broaden the availability of person-centered lactation education and support services across pregnancy, birth, and the postpartum also have positive impact on lactation and human milk feeding outcomes among perinatally incarcerated populations. Health care providers should support lactation education by discussing issues that have been documented as important to incarcerated birthing people such as lactation in the context of diet, smoking, and substance use, recognizing that many women may not raise these concerns due to perceived stigma, misconceptions, and lack of any prior breastfeeding education. ²⁸

Health care provider training

Gaps in health care provider education are another structural barrier to implementing recommended lactation support during the delivery hospitalization for birthing parents who are incarcerated. To ensure birthing people have opportunities to bond with and breastfeed their infants,^9,10 educational opportunities are needed for health care providers to receive competency-based training in trauma-informed care and to evidence-based breastfeeding recommendations aligned with BFHI, ACOG, and AWHONN standards.^8–11,15,26 Given the lower rates of human milk feeding among infants with intrauterine opioid exposure born to incarcerated versus nonincarcerated women, ³⁴ more education is needed for health care providers on the benefits of human milk for all infants, especially those experiencing NOWS. Health care providers working with incarcerated birthing people should also be educated on relevant state laws and institutional policies and trained to collaborate with carceral staff to address barriers to keeping mothers and infants together.

Continuity of care

Providing continuity of lactation support would address the gap in linkage to services after returning to the community. Both ACOG and AWHONN recommend that health care providers collaborate across systems to support incarcerated parents to develop plans for accessing breastfeeding support and other health care needs on return to the community.^9,10 Four articles noted that addressing a breastfeeding mother's needs after release requires consideration of interrelated priorities for shelter, food, safety, SUD treatment, and employment.^11,13,15,30

One study described how staff from a health system and carceral center in Idaho worked to address this gap by collaborating with the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), to improve access to the breastfeeding peer counselor program, while also working to develop a home visiting program for mothers after release from the carceral facility. ¹⁷ These partnerships can reduce organizational siloes to more holistically provide services that support breastfeeding or pumping mothers as they reintegrate into their communities.

Data collection

Finally, there are notable gaps in data collection regarding the needs and experiences of incarcerated people related to breastfeeding. In their survey of prison and jails, Asiodu et al called for more data on barriers and facilitators to implementation of lactation policies and programs. ²⁵ Another survey focused on juvenile residential systems described a lack of mandatory reporting of pregnancy-related data and the need for more research to understand the needs of justice-involved pregnant youth both during and after incarceration. ²⁶ The lack of databases and modern technological infrastructure within carceral facilities impedes routine tracking of perinatal populations or their use of services. ²⁹

Shlafer et al called for research on the short- and long-term physiologic and mental health outcomes, and associated cost benefits, which result from supporting incarcerated mothers to breastfeed. ⁸ Another study called for research focused on HIV-positive incarcerated mothers to support their ability to bond with their infants and attain a sense of maternal self-efficacy when unable to breastfeed as desired. ²⁸ Future research on incarcerated women's breastfeeding and lactation support priorities should use a reproductive justice framework to address contradictions between promotion of breastfeeding as an idealized version of motherhood and the inability to autonomously parent within the carceral system. ³¹