Dr. Ruth Elwood Martin and Brenda Tole
When a friend told Ruth Elwood Martin that there was a need for a part-time family physician to work in a women’s correctional centre, her immediate thought was that there was no way she could work in a prison clinic. She perceived that it was the lowest kind of medical job, only for those doctors who were unable to find any other type of work.
Ruth is not sure what drew her to start practising medicine in a prison, but she did. On that first day in 1994, she felt like she was visiting another planet, passing through those gates, experiencing another world and learning from the people inside it. Ruth saw more pathology and more tragic medical diagnoses than she had seen in a year in her regular family practice in Vancouver’s West Side.
In the clinic, women told her about traumatic events they endured as children, young teenagers and women. Ruth would put down her pen, bearing witness to their lives, and listen to medical and social histories she could not imagine enduring. That first day in her new position changed Ruth’s life forever and she knew that prison health would become her calling. Ruth has often reflected that if she had been dealt the same childhood cards as the women she met, she might be sitting in their chairs.
In 2003, Brenda Tole was assigned to oversee the remodelling of an older facility that had housed provincially incarcerated men and to open it as the “Alouette Correctional Centre for Women” (ACCW), a medium-security facility to house provincially sentenced women. If you are a parent with school-aged children, you will have noticed how the school principal greatly influences the overall ethos of a school. In a similar manner, the warden of a prison influences the ethos of the institution, which in turn influences the overall health of the inmates.
From the day it opened in 2004, Brenda shaped the tone and ethos of ACCW. She maintained that if you expect both staff and incarcerated individuals to treat each other with respect, they will rise to meet those expectations, at least most of the time. That’s how she planned and that’s how she ran ACCW, not on the basis that 1% of the population may breach those expectations.
Brenda knew that the more she gave people opportunities, the more they valued the opportunities and responded positively. The more she gave responsibility to the women for doing things themselves, and the more she talked with the staff about her plans, the better the situation would be for everyone.
During a meeting of key health care players planning for health care delivery at the new ACCW, Brenda met Sarah Payne, the director of Fir Square at BC Women’s Hospital, a maternity unit for substance-using mothers. Babies who remained with moms at Fir Square had positive health outcomes compared with the health of babies that were taken away from their moms at birth.((Ronald R. Abrahams et al., “Rooming-in Compared with Standard Care for Newborns of Mothers Using Methadone or Heroin,” Canadian Family Physician 53:10 (October 2007), http://bit.ly/2k4K29I.)) Sarah asked Brenda to consider the possibility that babies born to incarcerated mothers who came to the BC Women’s Hospital for their delivery might return with their mothers to ACCW, in order to foster breastfeeding, attachment and nurturing.
Separation through incarceration negatively affects the health of new mothers and their infants
With peer-reviewed academic literature growing on the subject, Brenda had good reason to consider this proposal. Evidence shows that one of the most compelling motivators for incarcerated women is pregnancy and their children. International correctional practices that promote contact between women and their children have shown benefits for both. Positive results have been seen in visits, email, tapes, telephone calls and letters. Children of incarcerated women are negatively impacted if the contact with their mother is limited or absent. Although it is accepted around the world that nursing infants and/or small children benefit from remaining with their incarcerated mothers, this was rarely seen in Canada at that time.
Many incarcerated women have dependent children. Worldwide, an estimated 6% of incarcerated women are pregnant while serving prison time.((Marian Knight and Emma Plugge, “The Outcomes of Pregnancy Among Imprisoned Women: A Systematic Review,” BJOG: An International Journal of Obstetrics and Gynaecology 112:11 (December 2005), doi.org/10.1111/j.1471-0528.2005.00749.x.)) An estimated 20,000 children each year are affected by the incarceration of their mothers in Canada,((Alison Cunningham and Linda Baker, Waiting for Mommy: Giving a Voice to the Hidden Victims of Imprisonment. London, ON: Centre for Children and Families in the Justice System, 2003.)) where women tend to be held in correctional centres that are large distances from their children and families due to the limited number of correctional facilities for women across the country.
The provision of mother–child units to women in prison who have given birth to their infants while incarcerated is considered normal practice in most countries in the world. Published reports of such units exist for 22 countries, including England, Wales, Australia, Brazil, Denmark, Finland, Germany, Greece, Italy, the Netherlands, New Zealand, Russia, Spain, Sweden, Switzerland, some US states, Kyrgyzstan, Ghana, Egypt, Mexico, India and Chile.((Helen Fair, “International Profile of Women’s Prisons,” World Prison Brief (February 7, 2008), http://bit.ly/2knx0BM.))((Kiran Bedi, It’s Always Possible: Transforming One of the Largest Prisons in the World. New Delhi: Stirling Paperbacks, 2006.))((Women’s Prison Association, “Mothers, Infants and Imprisonment: A National Look at Prison Nurseries and Community-Based Alternatives,” Institute on Women & Criminal Justice (May 2009), http://bit.ly/2hwPK0L.))
One of the reasons for keeping incarcerated mothers with their newborn babies is that it facilitates breastfeeding, which the World Health Organization reports has health benefits for the infant and new mother.((World Health Organization, “Infant and Young Child Feeding,” Fact Sheet (September 2016), http://bit.ly/1o6MEg8.)) According to international health experts, babies should be exclusively breastfed until they are six months old if possible, and then continue to be breastfed on demand until they are two years of age. Babies who are not breastfed may be at increased risk for diabetes, allergies and gastrointestinal and respiratory infections.((Health Canada, “Nutrition for Healthy Term Infants: Recommendations from Birth to Six Months,” A joint statement of Health Canada, Canadian Paediatric Society, Dietitians of Canada, and Breastfeeding Committee for Canada (2013), http://bit.ly/LTH03C.))
In addition to the well-known health and nutritional benefits, some research has shown that breastfeeding can contribute to psychosocial development((Grace S. Marquis, “Breastfeeding and Its Impact on Child Psychosocial and Emotional Development,” Encyclopedia on Early Childhood Development (March 2008), http://bit.ly/1cESBkC.)) – the associated physical contact, eye contact and the quality of feeding promote mother–child attachment. However, establishing and maintaining breastfeeding on demand is not possible unless mothers and babies can be housed together with 24-hour contact.
Typically, mothers who return to prison without their babies after giving birth are prescribed milk-binding pills and are often prescribed antidepressants. In this situation, many mothers experience profound grief and debilitating guilt, despair and hopelessness. Many resort to substance use as a coping strategy.
Mother–child unit developed to support well-being of incarcerated mothers and their babies
In 2005, Brenda asked Ruth, “As the prison physician, what is your opinion about the idea of incarcerated women who deliver babies in hospital being able to return here with their babies?” Ruth felt it was the most sensible idea she had heard in years, and she then expanded her prison medical practice to perform new roles, such as newborn examinations, breastfeeding coaching and addressing medical questions about newborns.
Through collaboration and partnership with several other ministries and community agencies, a mother–child unit was developed at ACCW based on the best interests of the child. With the support of Corrections Branch Headquarters, the ACCW health care team, correctional staff (both managers and frontline staff) and other provincial ministry personnel, it was decided ACCW could facilitate the return of mothers and babies to ACCW when recommended by BC Women’s Hospital and agreed to by the Ministry of Children and Family Development (MCFD), who had final authority over the placement of the child.
The decisions to place the mother and child together at the correctional facility were made by an interdisciplinary team consisting of the key staff from BC Women’s Hospital, ACCW health care, ACCW administration and the MCFD. If the mother was Indigenous, the pertinent Indigenous communities were consulted, when applicable. The mother and her family were included in all stages of this process. The support and services that Fir Square offered the mother before and after the birth fostered the mother’s confidence in parenting and in participating in the planning of her future and that of her baby. All checks and balances were put in place to ensure that ACCW was a safe and positive environment for the mothers and babies, with the cooperation of the mothers, other incarcerated women and correctional staff.
Incarcerated women who gave birth and who were deemed by MCFD able and willing to provide appropriate parental care were allowed to keep their infants in their care while in prison. During the initiative’s duration (2005–2007), 13 babies were born to incarcerated mothers, nine of whom lived in prison with their mothers and stayed there until their mother’s release. Eight babies were breastfed for the duration of their mother’s prison stay. Fifteen months was the longest stay of any infant in prison. The babies’ health and development was monitored by the community public health nurses, ACCW health care providers and MCFD social workers.
Release planning for the majority of the mothers and babies included placement at a residential supportive residence for women with substance use histories of the Fraser Health Authority, which took mothers and their young infants. The residential placement staff aimed to facilitate the transition of these women into the community.
Being involved in the initiative with BC Women’s Hospital had a profound positive effect on the women directly involved, the correctional staff and other incarcerated women, and the ministries and community agencies who partnered with ACCW.
Mother–child unit facilitates maternal involvement
Initially, other agencies and ministries were surprised and cautious regarding the proposal of the newborn babies returning to the facility with their mothers. The team at ACCW and BC Women’s Hospital took the time and facilitated many discussions and held meetings for all stakeholders to contribute to the program’s success.
Initially, the rights of the infant to be with the mother for attachment, bonding and breastfeeding was overshadowed for some by the feeling that this “privilege” should not be afforded to incarcerated mothers. As the initiative continued, the attitudes of many began to shift from cautious and guarded to comfortable and supportive. Community agencies were willing to provide supportive services to the children and mothers within the correctional facility. The collaboration reduced the need for ACCW to develop programs and services specific to the incarcerated population.
The mothers involved expressed great joy and were grateful that they could continue to breastfeed and nurture their babies at the correctional facility. They participated in parenting classes provided by a community agency through visits by the public health nurses and the MCFD worker. They also participated in health examinations by the ACCW physician to ensure the safety and health of their babies. Several of the mothers were permitted to go out into the community on escorted passes, both before and after the birth of their babies, to participate in various programs offered by community agencies that welcomed their participation.
Other women who did not have the opportunity to be with their children had to deal with the reminder of the pain they suffered as a result of being away from their own children. Seeing the babies at ACCW triggered feelings of loss, but a general feeling of hope permeated the entire population and the atmosphere at the facility was more positive in many ways. Incarcerated women wrote about their experiences as part of a prison participatory health research project, and their writing was later published in a book titled Arresting Hope.((Ruth Elwood Martin, Mo Korchinski, Lyn Fels and Carl Leggo, eds., Arresting Hope: Women Taking Action in Prison Health Inside Out. Inanna Publications, 2014.))
Seeing other ministries and agencies support this initiative had an impact on many of the incarcerated women. Most had very little trust in government agencies due to previous negative interactions. Seeing the agencies working together to ensure the babies stay with their mothers gave them a different perspective from which to view these groups. Some voiced a new interest to work with agencies to initiate contact with their own children with whom they had lost contact, or to work to improve their own lives to make a better life for their children.
For many, seeing the mothers and babies thrive at the facility and be released into the community together continued to reinforce the feeling that this initiative was not only the child’s right but also the right thing to do for the child.
Mother–child unit upheld by BC Supreme Court
In 2008, Brenda retired from ACCW and the BC Corrections Branch Headquarters shut down the prison mother–child unit. Amanda Inglis and Patricia Block, whose babies were born after the unit had closed, became appellants in a five-year legal case that led to a BC Supreme Court hearing in May 2013. During the women’s compelling testimony, Patricia told the court that there were as many as five different people caring for her daughter while they were separated. She tried to continue to breastfeed her baby while in prison, she said, but had difficulties in doing so.
At one point, her daughter’s foster mother stopped using the breast milk that Patricia had pumped because she worried it “wasn’t good milk.” Patricia had to inform the MCFD, who then ordered the foster mother to provide the breast milk to her baby. Patricia said that pumping milk in her prison cell for her newborn baby, who was then staying with relatives, gave new meaning to the phrase “crying over spilt milk.”
In December 2013, Honourable Judge Carol Ross ruled in Inglis v. British Columbia (Minister of Public Safety) that the cancellation of the mother–child unit infringed the Charter right to security of the person (section 7) of the mothers and babies affected by the decision, and that the infringements were not in accord with the principles of fundamental justice. The ruling also held that the cancellation constituted discrimination and violated section 15(1) of the Charter, the right to equality of the members of the affected groups, namely provincially incarcerated mothers who wished to have their baby remain with them while they serve their sentence and the babies of those mothers.
The judge directed the government of British Columbia to administer the Correction Act Regulation in relation to this issue in a manner consistent with the requirements of sections 7 and 15(1), and she gave six months to provide an opportunity for the government to correct the unconstitutionality of the present situation and comply with the Court’s direction.((Inglis v. British Columbia (Minister of Public Safety), 2013 BCSC 2309 (SC), H.M.J. Ross, http://bit.ly/2jiUVk0.))
Guidelines developed to facilitate program adoption across Canada
The Collaborating Centre for Prison Health and Education (CCPHE) hosted a two-day working meeting in March 2014 at the University of British Columbia to generate best practice evidence-based guidelines to inform the implementation of mother–child units across Canada. Experts were invited to present during four panel discussions entitled “The Rights of the Child,” “The Correctional Context,” “Pathways and Programs” and “Evaluation.”
Thirty stakeholder organizations were invited to contribute to the writing of the guidelines by selecting delegate representative(s) to participate in the working meeting. Delegates included those from BC Corrections Branch, Correctional Service Canada, New Zealand Corrections and Women in2 Healing (formerly incarcerated mothers).
The CCPHE contracted Sarah Payne to write an initial guideline framework based on her analysis of the meeting proceedings. A “content analysis” method was used to ensure that all themes developing from the meeting data were captured in the emergent guidelines. As a final stage, international resources and research publications, which had been presented by experts as evidence during the working meeting, were reviewed.
The resulting Guidelines describe 16 guiding principles and best practices required for optimal child and maternal health inside a correctional facility, including the correctional context, pregnancy, birth, education, correctional and medical care, discharge planning and community partner engagement. Delegates from BC Corrections Branch and Correctional Service Canada, who attended the writing meeting, incorporated the Guidelines’ principles and best practices into their respective organizations’ policies and procedures.
Follow-up evaluations of the mother–child unit currently under way
The ACCW mother–child unit was established on the principle that babies should accompany their mothers back to the ACCW, which was supported by the 2013 BC Supreme Court ruling that deemed it unconstitutional to separate the two. Currently, the “new” BC provincial program and the federal program (as well as programs in the U.S.) are based on the principle that it is a privilege for the incarcerated mother rather than a right: incarcerated pregnant women have to submit an application and go through a difficult, stressful and protracted approval process.
Some infants now currently reside with their mothers in federal women’s correctional facilities across Canada. However, bringing babies to live with their mothers inside provincial correctional facilities has been slow, even though a refurbished mother–child unit opened in July 2014 at ACCW. More education and understanding about the cultural, epigenetic, legal and permanent health impacts of a decision to remove a baby at birth can help support maternal and infant health in prisons across Canada.
A 10-year follow-up evaluation of the ACCW mother–child unit that ran from 2005 to 2007 is currently under way. Through in-depth interviews with mothers whose infants lived at ACCW, this evaluation is exploring their experiences and the current health and social development of their children.
Each of the mothers interviewed to date have reported that the decision to have her baby live with her in prison transformed her life. Each woman attributed the quality and quantity of time that she spent with her baby in ACCW to making a positive long-term impact on the mother–child relationship, and each reported that she now has an exceptionally close relationship with her child. Each woman also spoke very affectionately about her child’s attributes, with kindness and a caring nature as foremost.
Dr. Ruth Elwood Martin is a Clinical Professor in UBC’s School of Population and Public Health and recipient of the 2015 Governor General’s Award in Commemoration of the Persons Case.
Brenda Tole is the former warden at the Alouette Correctional Centre for Women from the time it opened in 2004 until her retirement in 2008.
Published on February 7, 2017