Incarcerated women in the US are particularly unwell and routinely denied access to quality healthcare in a system that was designed “by men, for men”. Through Ostara, Erica Gerrity transforms the experience of health education and prison birth and – in so doing – correctional facilities themselves.
A nova ideia
Prisons and jails in the US were designed “by men, for men.” However, today the fastest growing incarcerated population in the US is women (increasing 700% in the last 30 years), almost all of whom are nonviolent offenders jailed for drug or property related offenses. Behind bars, their needs are not being met. To meet the unique needs of women in prison and jails, in 2008 Erica founded the Minnesota Prison Doula project which - through a research partnership with the University of Minnesota and ten years of programming in facilities across Minnesota and Alabama - has become a national leader on women’s health in prisons. Their cost-effective model (that jails themselves pay for) makes one-on-one birth attendants or “doulas” available to expectant mothers, offers weekly pre-natal and parenting group sessions, and includes one-on-one counseling services where needed.
This is not a niche offering. A full 75% of women in prison are mothers, and 25% are pregnant or gave birth in the last year alone. Erica realized that intervening around the moment of childbirth can significantly help re-couple these currently severed identities and help women tap into strong feelings of wanting to do better by their children. Erica’s entry point into a system that usually resists outside influence rests on the fact that better births for mothers happen to be more affordable births for the facilities that house them, and morale is higher in prisons where women across the facility can stay more connected to their children and to their identity of caretaker and provider. For these reasons (and others), Erica’s approach works.
By carefully documenting their work throughout and having it evaluated by academic researchers – with results published in peer-reviewed journals – Erica raises awareness of the problem, shines a light on her solution, and has provided expert testimony that has helped passed legislation to end shackling of pregnant women and mandate access to birth attendants in five states, with the first and strongest set of legislation coming out of her base in Minnesota. Now, more than 120 jails and prisons around the country and dozens of doulas hoping to start programs have reached out for support. Through Ostara - a new vehicle for her work with a national mandate - Erica is providing in-person and online training, and strategically seeding multi-stakeholder clusters of changemakers (prison warden + nonprofit + healthcare facility, for example) who are replicating her success through new initiatives on the ground. In this way, she’s helping seed a national movement for quality care for incarcerated women led by champions of a model that works.
The US prison systems stands out globally, but not for many good reasons. While the country makes up just 5% of the world population, 25% of the world’s prison population resides in US facilities. In total, some 2.3 million people are incarcerated, and the fastest growing segment of that population – rising some 700% in just the last 30 years – is women. Most women behind bars are charged with nonviolent property or drug possession offences, and experts point to poverty and mental illnesses like depression and addiction as major contributing factors. The average age of a woman in prison is around 33 years old, and the averages length of prison stay is 66 months. Struggling with untreated mental health or addiction challenges and worried about the safety of their children outside, many women are routinely re-traumatized inside our nation’s “correctional” facilities.
This is in part because U.S. prisons and jails are designed “by men, for men.” From privacy to punitive measures, protocol between employees, and especially in access to healthcare, the culture of prisons and jails defaults to maleness. Accordingly, the general atmosphere is highly masculine; for decades most facilities have been designated “no touch,” and women who give birth will do so with prison guards but no family members in the room. The experience of women in prison is often of being in a particularly foreign, hostile land. Even the most widely parenting programming is based on traditional father figures. As just one measure of how women uniquely suffer – and try to cope – in such an environment, Andrea James of Families for Justice as Healing points to the fact that “more than half of the women incarcerated take some form of psychotropic medication during their time behind bars (compared to only 20% of male prisoners.)”
At 66%, the rate of births by cesarean delivery for incarcerated women is more than twice the national average. Despite greater risks for the mother and worse health outcomes for the baby, because prisons prioritize security and control and view birth as an emergency that they’d rather avoid, most births are scheduled cesareans. And women aren’t pushing back, in part because they have no prenatal education and don’t know what is going on. Erica points out that they are also often terrified and depressed, emotionally afraid to love their baby and scared that – after just two days – it will be taken away. This isn’t only true for the 25% of women incarcerated who are pregnant or have given birth in the last 12 months; for the 75% of women behind bars who are mothers, the daily trauma of wondering “where are my children, and are they safe?” also takes its toll.
Around the country doulas and birth workers – many directly inspired by Erica’s work - have tried in various ways to offer their support and intervene at this critical life moment. Almost all, however, have so far failed to get off the ground as prisons and the people who administer them are suspicious of outsiders, resistant to change, and – frankly – hard to work in. And denying access to healthcare is also strategic; Erica believes that when incarcerated people do not have access to health information or proper health care, they are left physically and emotionally too sick to advocate for themselves or to fight back against the injustices of the system.
So advocacy outside, then, must be an important part of any systemic solution. In recent years, the particular plight of women behind bars has become more visible, and Erica has helped advocate and provide expert testimony in five states where it is now illegal to shackle women in childbirth and legal for an incarcerated pregnant woman to request a birth attendant. But in 23 states shackling is still commonplace. While organizations and institutions across the ideological spectrum and around the country are increasingly calling for halving the prison population over the next decades, they will desperately need models that work and a practical path to get them off the ground.
In the 1980s and in response to an increased rate of cesarean deliveries in the U.S., the role of the doula or birth attendant emerged as an antidote to the dryness of the medical system. Trained on the changes a pregnant body undergoes, the way a baby is born, and all the ways that women can give birth, a doula says that “a good birth is whatever you want your birth to be.” Because women in the 1980s – just as incarcerated women today – had lost touch with what a birth looks like and weren’t experiencing the wide range of options as a choice, the doula’s job became to help a woman understand what birth options look like and make informed decisions, while providing companionship and emotional support along the way.
With a similar set of goals and through the Minnesota Prison Doula Project (formally re-launched as Ostara in 2018) Erica has refined and is now spreading a proven and effective model that increases incarcerated women’s access to health information and support, raises health literacy, measurably improves the health-based outcomes for justice-involved women and their children, and helps create space for the US prison system to change. After ten years refining and sharing the “Prison Doula Project” intervention, Erica is now launching a national organization called Ostara to replicate their successes and – through partners – to raise awareness, pilot evidence-based solutions, pass legislation, and dramatically change the experience of women’s healthcare in U.S. prisons and jails.
The central offerings that Erica recommends prisons and jails around the country make available – working in partnership with community groups that she helps train to deliver them – include one-on-one birth support from a trained doula before, during, and after birth; weekly facilitated 2-hour parenting and education groups (Pregnancy & Beyond and Mothering Inside); and access to individualized counseling support to help mothers cope with the stress of separation and strengthen relationships with their children. In addition to these core offerings, Erica has helped facilities create programs for lactation and breast milk banking and supervised visits for mothers and children, and they produce and distribute several printed pregnancy and parenting education resources.
Not only have these efforts decreased the rate of cesarean delivers in prisons in which they work by 200%, but they’ve measurably improved the mother’s mental health as well as the child’s health outcomes. Through on-the-ground programs that they deliver themselves in Minnesota and Alabama, they’ve also rigorously documented that change. It’s important to Erica that she knows that what she’s doing works. On top of that, collecting rigorous quantitative and qualitative data, using that evidence to refine programming, documenting impact of the improved evidence-based approaches, and then publishing major learnings in peer-reviewed journals helps provide a foundation for advocacy work, secure funding (including from the National Institute of Health), and “de-risks” her approach in the eyes of prison administrators. Drawing on her training in social work and public health, all program participants respond to pre-post surveys featuring standardized measures of depression and a “triple aim” score – along a 1-5 Likert scale – based on responses to questions about the level of support they are feeling. To date they’ve conduced 90 studies across the hundreds of interventions and thousands or participants. One of Erica’s most steadfast collaborators over the last decade is researcher and professor Dr. Rebecca Shlafer from the University of Minnesota, Department of Pediatrics. She and Erica have published four peer-reviewed publications and the two of them have given well over 300 public presentations in their efforts to disseminate their findings throughout the country.
Already 20% of their funding – a growing percentage – comes from earned-income and contracts with prison and jail facilities themselves. But that’s in Minnesota and Alabama where they have contacts inside facilities who write up referrals, that they then match to doulas in their state-wide network. As word of Erica’s model’s success has gotten out, she has begun convening a national networking group for current and aspiring professionals working at the intersection of women’s health and the US prison system. In these other places and with an eye at working at scale by sharing her model more widely, Erica is helping networks of prison administrators, funders, nonprofit agencies, and healthcare providers first find each other and then launch programs based on her model. As a first touch point, Ostara now hosts quarterly 90-minute interactive webinars featuring speakers, discussion, and project updates. They then follow-up with participants by curating connections between stakeholders with the same interests in the same states. Over the last year, individuals from 22 different states and from Canada have participated and 125 prisons or jails outside of Ostara’s current operating area have requested services. And in October 2018, as a way to ensure quality replication with high-fidelity outcomes to meet this demand, Ostara will also hold its first ever National Prison Doula Training where newly-formed multi-stakeholder groups from Michigan, Georgia, Chicago, Wisconsin, and Quebec City will come together in Minnesota to refine and eventually launch their own programs in Ostara’s model. Over the next 5-10 years, Erica believes they will be able to help launch programming in all the country’s 110 female prisons as well as in many more county jails and detention centers.
But changing the system at this level requires an additional strategic thrust. Elected officials and prison administers will have a role to play, especially in removing hurdles that the new Ostara-supported initiatives may face in getting launched. But Erica is experienced here, noting that the Minnesota legistation was the first and strongest, and will eventually be a format for a federal bill. Today, however, the way forward is state-by-state. A bill (WA HB2016) currently making its way through the Washington State House was modeled after Minnesota Prison Doula Project’s efforts and outcomes and, if signed into law, will permit certified midwives and doulas to provide prenatal care and counseling for pregnant inmates in otherwise “no touch” facilities, as well as assist them during labor and childbirth. And just this spring (May 2018), Erica and team helped pass legislation in Oklahoma that legally entitles incarcerated women to access to doula care. In reflecting on these developments, Erica notes that, “prison doula wasn’t a job when I was a little girl, but today it is. A decade of our tireless work made that a reality.”
Over time Erica hopes that her work will contribute to a complete end to shackling, full access to labor support, and a movement toward community-based alternatives for pregnant people and mothers with young children. Indeed, rebranding and relaunching as Ostara in 2018 wasn’t just a way to drop “Minnesota” from their name as their impact becomes more national. With a wholly owned (by the non-profit) for-profit subsidiary they are laying the groundwork to someday explore other avenues – like providing women’s health insurance coverage in facilities in which they work or, down the road, possibly even operating their own model correctional facility – to further advance their efforts from other angles, draw in even more partners, and expand the civic sense of what’s possible in the face of one of American’s most unique and complicated challenges.
Erica had a tumultuous, lonely childhood in rural Minnesota that was shaped by “chaos, emotional abuse, and neglect” and that ended abruptly when, at 16, her mom walked out on her and her sister. Finding herself homeless, she enrolled in college and graduated at age 19, quickly finding work as a social worker “because I was so curious about pain and loss. I wanted to explore it like a scientist, to make sense of suffering and come to know healing.” Looking back now, Erica notes that it was “the loneliness of my childhood that made me connect with prisons. It was a place of unavoidable truth and suffering. I had developed an incredible tolerance for such emotional spaces and my depth of empathy for others who were survivors pulled me through my days.”
At the age of 23 Erica fell in love with the words and work of Ina Mae, author of “Guide to Childbirth” and a leading expert on midwifery and natural birth. Later that year, Erica became a doula. “Through birth work and prison work, I have come to know the love and community of other women. They’ve helped me to better understand the mother sickness I’ve suffered from and to be honest about my experiences, to ask for help, be vulnerable, and to be a source of healthy love and support for others.”
In 2008, Erica conceived of, bootstrapped, and launched the Minnesota Prison Doula Project during the economic downturn. Formerly housed in a community-based women’s health organization at which she volunteered, and working at the whim of a skeptical prison warden, she quickly and clearly made the case that her intervention worked, and by 2013 had expanded from one prison in Minnesota to the state’s largest county jails (which, unlike her pilot prison, directly paid for her team’s services). In 2014 she provided expert testimony that helped the Minnesota legislature pass the first law in the country to mandate access to doula care should an incarcerated mother desire it, and today Erica continues to serve as a member of the legislative advisory committee set up by the law to consider the supports to pregnant and postpartum incarcerated women, to secure state funding for the mandate, and to oversee its implementation.
When the time is right, Erica will rally the national Ostara network and design and launch a model community-based prison. Presently, judges tasked with doling out punishments where individuals convicted of crimes are fed, kept away from society, and not let out – as “simple” as that may sound - have very limited options. While working to reform the old, Erica also believes that in some cases we will need to build from the ground up the alternative infrastructure where people can serve their time, get treatment, pay their debt to society, and also learn new things about themselves and their role in the world. In the meantime, Erica and the Ostara team and community will continue to grow the national network of independent replicators and lend support to related causes.