Pregnant Women in DOJ Custody: U.S. Marshals Service and Bureau of Prisons Should Better Align Policies with National Guidelines

In January 2021, we reported on various issues related to pregnant women in U.S. Marshals Service (USMS) custody. We found that USMS did not identify or track which women in its custody were in postpartum recovery. As a result, USMS did not have awareness of postpartum women in its custody and were not positioned to ensure their treatment and care in accordance with USMS policy. We recommended that USMS develop and implement a policy to identify and collect postpartum data starting with the intake process. USMS agreed with this recommendation. In response, in May 2022, USMS updated its policy on prisoner restraints to include a reference to postpartum status in each instance in which pregnancy is mentioned. In addition, USMS updated its policy directing USMS personnel to ask female prisoners if they are pregnant or in postpartum recovery at intake. Further, USMS added a postpartum status option to its prisoner management database and developed a webinar to train personnel on how to add such information in the database. Effective July 2022, USMS modified the database to include a new postpartum pregnancy question to the medical questionnaire section used at intake. According to USMS officials, the database prompts the user to enter information describing the prisoner's existing medical conditions, such as postpartum status, before permitting the user to proceed to the next step of the intake process. These actions meet the intent of the recommendation to identify and collect postpartum data starting with intake, and, as such, the recommendation is closed as implemented.

In January 2021, we reported on various issues related to pregnant women in U.S. Marshals Service (USMS) custody. We found that USMS had not updated its Detention Standards to reflect prohibitions on the use of restraints for pregnant and postpartum women. Specifically, USMS's intergovernmental agreements (IGAs) with state and local governments required facilities to follow the 2017 Detention Standards which did not include the restraint prohibition. As a result, women in USMS custody continued to be held in facilities that did not restrict the use of restraints on pregnant and postpartum women. We recommended that USMS develop a plan with a timeline for updating its Detention Standards to reflect the updated policy restrictions on the use of restraints on pregnant and postpartum women. USMS agreed with this recommendation. In response, in November 2022, USMS provided us with its Detention Standards, which were updated in December 2021 to include restrictions on the use of restraints for pregnant and postpartum women. In addition, USMS provided us with an updated intergovernmental agreement template that includes language restricting the use of restraints on pregnant and postpartum women. Further, according to USMS officials, in January 2022 USMS began a process to modify all existing intergovernmental agreements to comply with a voting access executive order. As part of that effort, USMS modified these agreements to include the restrictions on the use of restraints on pregnant and postpartum women. According to USMS officials, in May 2022, USMS sent modified agreements to all IGA facilities with an existing agreement. As of December 2022, USMS officials stated that 70 percent of facilities responsible for housing approximately 85 percent of the USMS detention population have endorsed and returned the modified agreements to USMS. USMS officials stated that they continue to work with the remaining IGA facilities with outstanding modifications. As a result of these actions, the recommendation is closed as implemented.

In January 2021, we reported on various issues related to pregnant women in Bureau of Prisons (BOP) custody. We found that while BOP has policies that address the treatment and care of pregnant women, not all policies fully aligned with national guidance recommendations. Specifically, BOP policies either partially aligned or did not align with such recommendations in 8 of 16 pregnancy-related care topics. The partial alignment or nonalignment of BOP policy with national guidance recommendations we identified-particularly in the areas of nutrition, prenatal, labor and delivery, and postpartum care-increased the risk that pregnant and postpartum women may not receive treatment and care in accordance with national guidance recommendations. We recommended that BOP take steps to more closely align its policies with national guidance recommendations on pregnancy-related treatment and care, as feasible or appropriate. BOP agreed with this recommendation and has taken actions to address all of these gaps. Specifically, in June and December 2021, BOP provided us with documentation showing that it had updated its policies and guidance in five topics areas-mental health services and counseling, pregnancy testing at intake, provision of postpartum care, provision of prenatal care, and use of restraints-to address the gaps we identified and to be fully aligned with national guidance recommendations. For example in regard to the gaps we identified in the mental health services and counseling topic area, BOP developed technical guidance specific to pregnant and postpartum women that has more detailed requirements on mental health assessments. In March 2022, BOP provided updated guidance that addressed the gaps we identified in remaining three topics areas-provision of labor and delivery care, substance use disorder care, and nutrition. For example, BOP added requirements for nutritional assessments for pregnant and postpartum women to its technical guidance. These actions better position BOP to help ensure the health of pregnant and postpartum women in its custody. As a result, this recommendation is closed as implemented.

In January 2021, we reported on issues related to pregnant women in Bureau of Prisons (BOP) custody. We found that BOP does not identify women in postpartum recovery during the intake process. As a result, BOP was unable to ensure that postpartum women receive medical services and are not unnecessarily restrained. We recommended that BOP develop and implement a policy to identify and collect data on postpartum individuals during the intake process. In October 2021, BOP added an obstetrics and gynecology (OB-GYN) module to its medical records System-Bureau Electronic Medical Records (BEMR). This module, among other things, has a data field for BOP Health Services to staff to document if an individual is postpartum. BOP developed user guides for the OB-GYN BEMR module and held a training session for staff on how to use the module. These actions will better position BOP to identify and collect postpartum individuals during the intake process. In addition, BOP can better ensure its staff has the information needed to provide appropriate postpartum care in accordance with its policies, and that BOP corrections officials do not unnecessarily restrain postpartum women. As a result, this recommendation is closed as implemented.

In January 2021, we reported on various issues related to pregnant women in U.S. Marshals Service (USMS) custody. We found that although USMS requests that its intergovernmental agreement and contract facilities submit data on a regular basis to USMS on individuals in USMS custody placed in restrictive housing, facilities are not required to indicate whether any of these individuals are pregnant or postpartum. National guidance recommendations state that pregnant and postpartum women should not be placed in restrictive housing except in very rare situations where the individual poses a serious and immediate risk of physical harm. We recommended that USMS should require its intergovernmental agreement and contract facilities to collect data on and immediately notify USMS when pregnant or postpartum women are placed in restrictive housing, so that USMS can help ensure appropriate use of such housing in accordance with its policies. USMS agreed with this recommendation. In response, in January 2022, USMS stated that it has added a restrictive housing component to its prisoner management database in September 2021, which also includes a data field to indicate pregnant or postpartum status. USMS officials said that administrators from facilities with which USMS has an intergovernmental agreement are required to report in the database information on when an individual in USMS custody was placed in restrictive housing. In May 2022, USMS officials provided us with a user guide directing administrators from facilities with which USMS has an intergovernmental agreement on how to enter restrictive housing data in the system, including entering data on pregnant or postpartum status. Further, according to USMS officials, USMS will coordinate with USMS district personnel to ensure that any e-mail or verbal notifications of restrictive housing placements by intergovernmental agreement facilities are reported in the database. These officials said that the districts will validate the reported restrictive housing placements as part of the annual detention facility reviews conducted of each facility. In addition, USMS developed an updated intergovernmental agreement template that identifies pregnant and postpartum individuals as a vulnerable population, and indicates the conditions under which these individuals should be placed in restrictive housing. According to USMS officials, in May 2022 USMS sent modified agreements that included notification requirements for the placement of restrictive housing of pregnant and postpartum women to all intergovernmental agreement facilities with an existing agreement. As of December 2022, USMS officials stated that 70 percent of facilities responsible for housing approximately 85 percent of the USMS detention population have endorsed and returned the modified agreements to USMS. USMS officials stated that they continue to work with the remaining intergovernmental agreement facilities with outstanding modifications. With respect to contract facilities, USMS officials said that restrictive housing reporting requirements do not apply. Instead, on-site Detention Contract Monitors monitor compliance with USMS Detention Standards and policies, including restrictive housing policies. USMS stated that, as of April 1, 2022, Detention Contract Monitors will be required to record whether a female housed in restrictive housing is pregnant or postpartum, which is a new requirement. USMS officials said that contract facilities themselves are contractually required to notify USMS district officials of such incidents in accordance with Federal Performance Based Detention Standards. These actions meet the intent of the recommendation, which is to require that intergovernmental agreement and contract facilities immediately notify USMS when pregnant or postpartum women are placed in restrictive housing. As such, this recommendation is closed as implemented.