Birth supporters experiences of attending prisoners being compulsorily separated from their new-born babies

ABSTRACT

There is growing evidence demonstrating increased mental ill-health in women compulsorily separated from their babies. For imprisoned women, the risk of self-harm and suicide may be further exacerbated. Birth supporters caring voluntarily for women in prison having their babies removed is valued and beneficial for wellbeing. Little is known about the effects on those supporting women in these circumstances. The aim of this study was to better understand the experiences of birth supporters when caring for imprisoned women experiencing compulsory separation from their babies. A qualitative approach explored the experiences of 12 birth supporters through: one to one in-depth online interviews. A thematic analytical method was utilised to analyse the data. Four key themes resulted from thematic analysis: vicarious trauma, transference of pain, standout cases and support networks. Birth supporters witnessing traumatic events such as the separation of imprisoned mother from her new-born baby may need additional supervision and therapeutic support. Birth supporters may experience Secondary Traumatic Stress (STS) and appropriate support and debriefing should be afforded to them equal to paid health and social care staff. The main argument of this paper is that strong support networks can serve as a benchmark for helping individuals affected by vicarious trauma, particularly in complex situations involving women who are being compulsorily separated from their babies. Due to the value clearly placed upon those who do volunteer by women, this kind of support should be consistent across criminal justice settings especially considering the impact on women’s mental health and wellbeing.

Keywords:

• Prison
• Birth supporters
• Compulsory Separation
• Newborn baby
• Mothers

Introduction

There is growing evidence to show an increase in mental ill-health in all women compulsorily separated from their babies (Broadhurst et al. 2015, 2017; Knight et al. 2021). For imprisoned women, the risk of self-harm and suicide may be further exacerbated (Baldwin 2018; Abbott 2021). Recent research (Abbott 2021) has built upon findings in that the anticipation of separation of an imprisoned mother from her newborn baby elicits feelings of loss (Wismont 2000; Schroeder and Bell 2005; Chambers 2009). Qualitative research has also found that prisoners experiencing enforced separation from their newborn babies endure disenfranchised grief and a sense of lost identity (Abbott 2021). There is currently no official guidance for mothers in prison losing babies through enforced separation. However, academics and charities are modelling best practice through working together with experts by experience to co-produce practical and creative solutions (Mason and Chivers 2021; Martin and Powell 2022). Minimum recommendations include tailored training for all involved in prisoner health to understand the complexity of this type of grief and the consequent dangers to health.

Kivlighan et al. (2022) have provided evidence to suggest that accessing doula services that meet the needs of diverse groups, such as pregnant prisoners, can help mitigate some of the negative effects of health inequalities. Similarly, McLeish and Redshaw’s (2017) qualitative descriptive study, which explored volunteer support for disadvantaged mothers affected by criminal justice settings, identified various challenging issues faced by volunteers. These included the need to maintain a non-judgmental attitude and establish clear boundaries when supporting women from complex backgrounds. In 2015, Spiby et al. conducted a comprehensive mixed-methods evaluation of volunteer doula support in the UK. The study revealed that volunteer doulas were highly valued by women, particularly in instances where access to midwifery support was limited. The women reported experiencing positive psychosocial impacts as a result of their interactions with the volunteer doulas. The doulas themselves reported experiencing a sense of satisfaction from being able to make a difference and gratitude for their own personal experiences. However, they also reported feelings of guilt and sadness when a woman had a traumatic birth experience. In a similar vein, Shlafer et al. (2015) documented how doulas working with pregnant women in prison were able to establish a successful, trusting, and empowering relationship with their clients. This relationship enabled the doulas to provide meaningful support to women who were separated from their babies shortly after giving birth. Taken together, these findings suggest that volunteer doula programs have the potential to provide valuable support to women during pregnancy, childbirth and postpartum. They also highlight the emotional complexities involved in providing this support, both for the women being served and for the doulas themselves.

Support for separating mothers in some English prisons are provided by charities who have specialist expertise in labour and birth. Organisations and charities intended to meet the needs of disadvantaged, diverse and underserved perinatal communities are reportedly well received by women and the volunteers who assist them (Delap 2019; Machtinger et al. 2019; Shlafer et al. 2021; Kivlighan et al. 2022). Marshall (2021) described how the UK charity Birth Companions who provide tailor made support for perinatal women involved in criminal justice system (CJS) offer a valuable way of supporting volunteers. This provision delivers a useful framework for trauma informed healthcare, including situations where a prisoner may have her baby removed at birth, especially where a birth supporter may have been the main carer. Thomson’s (2023) study found that Birth Companions’ perinatal support improved incarcerated pregnant women’s healthcare access and satisfaction, as well as their mental health outcomes. However, COVID-19 restrictions presented challenges for both Birth Companions and clients. To enhance support, the study recommended increased mental health services, better healthcare provider training, and more resources for support organisations. Models of supportive supervision such as those provided by charities like Birth Companions in the UK offer a thoughtful model for compassionate care and therapeutic support for volunteers and birth supporters. Building on evaluations of doulas experiences working with disadvantaged groups, this paper examines the experiences of birth supporters attending imprisoned women who are being separated from their babies.

Methodology

An exploratory study qualitative design was established to better understand the experiences of those supporting women in prison experiencing compulsory separation from their babies. Favourable ethics approval was obtained from University of Hertfordshire Research Ethics Committee. Protocol number: HSK/SF/UH/04236. One to one in-depth audio recorded interviews with 12 women birth supporters took place online. The author is a qualified and experienced midwife, teacher and mother with experience of undertaking prison research. Pre-understanding of the author having supported women being separated from their newborn babies meant self-reflection helped to eliminate as much bias as possible when interviewing and analysing the data.

Sample criteria

Birth supporters who volunteer to provide charitable support for pregnant women and new mothers in prison who have direct experience of supporting women who have been compulsorily separated from their babies. Potential participants were identified through social media and online communities. Snowball sampling, which involved asking participants to refer others who might be eligible for the study was also utilised.

Analysis

A thematic analytical approach was used to analyse the data (Braun and Clarke 2012). To support the early manual colour coding, NVivo, a computer-assisted qualitative data analysis software (CAQDAS) was selected to help to organise the data. Using NVivo, 78 nodes were established linking to 14 categories. Adjustment condensed the data to a more practical state with 42 nodes and grouped into four themes resulting in a more manageable dataset for analysis.

Results

The following details findings resulting from the thematic analysis. Birth Supporters accounts are drawn on to explain their experiences, including exemplar quotes of the 12 participants interviewed. Pseudonyms are used throughout.

Standout cases

In each of the interviews, all 12 Birth Supporters described a specific case that stood out for them. These were usually spoken about without specific prompting from the interviewer. This frequently involved something about the woman being separated from her baby that caused the participant upset and distress. The feelings evoked made the situation especially memorable. Janice explained that one woman she had built a positive relationship with rejected the support offered following removal of her baby:

She was one of those people who I think maybe you could have broken the mould with … we could have given her time and support if only she was given the opportunity to be allowed to keep her baby, but after the baby was taken, she didn’t want any contact with us anymore. The trust was gone. I think she just wanted to forget. It is because it’s a different type of loss because of the stigma attached to it, and the guilt … it is not an acknowledged loss. I think the pain was literally too much for her to bear and myself and the other volunteers were reminders of that loss and pain. (Janice)

Tida explained that a woman who particularly stood out to her was someone expressing painful emotions and grief following removal of the baby:

She had had multiple removals from her teenage years. Her addiction was overriding every type of maternal instinct … She was pregnant but dreaded that the baby would be adopted. It was almost like she wasn’t entitled to the same sort of care the ‘normal’ woman would have. The intense grief was extremely distressing for everyone involved. (Tida)

The standout cases often crossed over with the themes of transference (Freud 1912) and vicarious trauma due to their haunting nature. This often came from witnessing intense grief reactions and unforgettable scenarios described.

Transference of pain

A key finding was how painful emotions of the incarcerated women being separated from their babies sometimes felt as though the hurt was subconsciously passed onto the birth supporter. Geetika described how being with a woman being separated from her new-born baby felt for her:

Her pain was so raw, I’ve never really felt anything like that, I felt from a spiritual perspective it was like she was pouring this pain into me so I could metaphorically take it [the pain] out of the prison and away from her. (Geetika)

Tammy described what this emotion felt like:

The raw grief was extremely distressing for everyone involved … it’s a transference of pain … it is an unacknowledged loss, a different type of loss because of the stigma attached to it and the guilt that women feel. I won’t ever forget it. (Tammy)

The transference of painful emotions was a phenomenon described by many of the birth supporters who demonstrated empathy with the women but found caring in these circumstances complex and unforgettable.

Vicarious trauma

Some supporters described how they experienced witnessing the separation of a mother from her baby as a personal trauma themselves, even though they were providing care rather than personally experiencing the distressing event.

Jenna described it as:

Most people do not expect to witness this type of trauma … it’s a type of vicarious trauma that is extraordinary to most human experiences. Sometimes there’s been a situation where there’s been a delay and the mother hasn’t actually been able to hold her baby after the birth which is really terrible.

Jenna went on to elaborate

It can lead to the birth supporter feeling that perhaps they haven’t been able to do everything they could for that woman and feeling perhaps they have failed the woman and they haven’t been able to ensure separation was done in a way that hasn’t minimised the trauma … often it can feel like being almost in the same situation as the woman suddenly finding out [that separation is going to happen] and having to deal with that. (Jenna)

Jenna explained how some women would not know about the separation occurring until after she had given birth. The birth supporter would also be unaware in these circumstances. The displaced trauma experienced by birth supporters, similar to a transference of pain was often difficult to process and usually led to some situations being especially haunting:

… I think the fact that women are inevitably going to go on thinking about that child that’s been separated from them. And to kind of do whatever we can to minimise the kind of grief and pain that comes from that, is really important … it is difficult and can be upsetting … the situation gets under your skin and kind of lingers there for a long time. (Izzie)

Support networks

Especially valued by the birth supporters was the meaningful support they experienced through debriefing and supervision. There was an acknowledgement that this kind of specialist attention was definitely needed. Holly suggested:

I think there needs to be a lot of support for everyone involved in these situations [separations] and perhaps that isn’t always acknowledged. (Holly)

On feeding back about the type of support received Gita appreciated the trauma informed approach taken towards the volunteers:

Even in a very extreme situation there could be some small things, acts of kindness, which actually made the situation a bit more bearable and compassionate. Support networks are fairly solid … Staff and volunteers [birth supporters] are looked after in that same trauma informed way as women are as far as possible … something volunteers say is missing from some other organisations. (Gita)

Given the conveyance of pain from woman to supporter together with the potential for distress, meaningful, trauma-informed support was particularly important to the birth supporters:

… Working in a small, supportive team is essential. Because, as an individual, you need to feel safe in expressing and advocating for that woman. And you can help build each other up when you’re working in a small team, and that can then change other people’s opinions. (Izzie)

The team’s small size seemed to create a supportive and nurturing environment, rather than the detachment that can be found in larger organisations. The intimacy and cohesion of a smaller team may have contributed to a greater sense of belonging and care among supporters.

Discussion

The study involved interviews with 12 birth supporters who were all volunteers working with incarcerated pregnant women. The research explored the birth supporters’ experiences and the emotional impact of supporting these women through pregnancy and childbirth, particularly with regards to the separation of the women from their babies. The birth supporters shared several standout cases that they found particularly memorable, often involving intense grief reactions and scenarios where the women were separated from their babies. The emotional pain of these experiences was sometimes felt by the supporters themselves, leading to transference of pain and vicarious trauma. Despite the emotional challenges, the birth supporters found their work to be rewarding and felt a sense of purpose in supporting these women. They also valued the support they received from debriefing and supervision, which helped them to process and cope with the emotional demands of their role. What follows is a discussion of these key issues.

The descriptions of vicarious trauma together with the transference of pain from birth supporters are important to acknowledge due to the potential distressing nature of bearing witness to extreme events. An area not so well identified within the third and voluntary sector is the potential for secondary traumatic stress (STS) triggered by supporting traumatised individuals and witnessing upsetting events (such as mothers being separated from their babies). The literature does describe the phenomenon of secondary traumatic stress (STS) but mainly where paid, permanent health and social staff are witness to traumatic events whilst caring for clients/patients (Bride et al. 2004; Beck 2011; Barleycorn 2022). Conversely, as demonstrated in the dearth of literature, there may be little attention paid to those who may be volunteers or undertaking unpaid altruistic, charity work supporting those who may be in distress or have a harrowing narrative (e.g. mothers being separated from their new born babies). Often described by psychoanalysts as a projection of feelings about someone else onto a therapist (Cartwright 2011) a key finding of this study was how the raw emotion and trauma of separation experienced by the woman often felt personal to them, as if pain was being transferred subconsciously into the birth supporter. The term ‘raw’ was frequently used to describe the intense emotions that were observed during the process of separation and the emotional reactions expressed by the birth supporters as they recounted their own experiences.

Secondary traumatic stress (STS) has been documented as being a particular issue where staff may witness distressing events (Bride et al. 2004; Beck 2011). It is without doubt that closely supporting those experiencing separation may include witnessing upsetting responses to the separation including extreme anguish, disassociation, disenfranchised grief and stigma Abbott et al. (2021). In turn, STS may become an issue for staff and birth supporters instigating burnout and compassion fatigue. It is well recognised that doulas and birth supporters feel greatest satisfaction when valued, supported and mentored (Shlafer et al. 2015; Spiby et al. 2015; Marshall 2021; Kivlighan et al. 2022).Therefore, to be able to debrief in a trauma informed and safe space means that birth supporters can continue to give the empathy and care, knowing that support is also there for them as well as the women they are caring for.

Caring for the care givers was considered an important way of empowering birth supporters to appropriately support the women being separated from their babies. O’Rourke et al. (2020) explains how important doula and birth support is, especially with maternity services under increased strain. This builds upon Spiby et al. (2015) findings whereby volunteer doulas appreciated supervision, specifically ‘buddying and mentoring’ whilst they supported women, especially those who may be experiencing trauma. Shlafer et al. (2015) feasibility study demonstrated that doulas may need specific training and a greater understanding of their own resilience and personal coping mechanisms in order to best support imprisoned women separated from their babies following birth. Machtinger et al. (2019) research included doulas working with women who may have a trauma history or misuse illegal substances. Having a trauma informed framework approach utilised a ‘trauma lens’ i.e. assuming all those seeking healthcare may have come from a place of past abuse and trauma, requiring empathy and healing. Furthermore, adopting a trauma informed approach to supporting birth supporters and doulas was noted as an important component of supervision.

Marshall (2021) outlines how women having their babies removed from them shortly after birth, experience this as extreme trauma, especially those in prison who may have already endured traumatic events such as being trafficked or fleeing war. Barleycorn (2022) highlights how STS can lead to staff burnout, increased sickness levels and reduced job satisfaction in emergency staff. The charity Birth Companions developed a model encompassing trauma informed approaches for the women they care for and the volunteer birth supporters who support the women and suggest rolling out a national trauma informed maternity service as a country wide policy (Delap 2021). Prioritising the care and well-being of birth supporters can involve providing them with resources for coping with stress and trauma, such as access to counselling or support groups. The influence of birth supporters on women’s distressing and vulnerable situations during childbirth is undeniably significant. However, it is essential to recognise the importance of compassionately caring for the birth supporters themselves to prevent burnout and STS, which can ultimately compromise the quality of care provided to women.

There are several strengths of this study including being an in-depth exploration of the experiences of birth supporters working with incarcerated women who have experienced separation from their newborns. This provided a unique insight into a specific population and the challenges they face in providing support to incarcerated mothers. The use of in-depth interviews allowed for a flexible and detailed exploration of the participants’ experiences, providing rich and detailed data. With the interviews being conducted online, interviewer bias was reduced due to potentially feeling more comfortable and at ease in their own environment (Mathner et al. 2012; Thunberg and Arnell 2022; Abbott et al. 2021). Online interviews were time efficient and made it easier to reach a larger pool of participants from around the country, including those in remote or hard-to-reach areas. The study also highlights the importance of trauma-informed care and support for both incarcerated mothers and birth supporters, accentuating the need for policy and practice changes to better support this vulnerable population.

A limitation of the study is that it did not explore the experiences of the incarcerated pregnant women themselves. This could have provided valuable insights into their perspectives and experiences of being separated from their newborns. Due to the COVID-19 pandemic, all interviews had to be conducted online, which was a necessity. However, this posed technological challenges for both the participants and the researchers and required participants to develop a new skill. Despite the advantages of undertaking online interviews, the inability to conduct in-person discussions resulted in the loss of important visual cues and nuances that could only be captured in face-to-face interactions.

Implications for practice and policy

When women are in distressing and vulnerable situations, such as experiencing compulsory separation from their newborns, the presence of birth supporters can make a significant positive impact on their well-being. However, it is important to ensure that these birth supporters are also cared for with compassion. This includes providing appropriate support and debriefing, as well as compensation for their time and efforts. Marshall (2021, 218) the Head of Services at the charity Birth Companions, suggests that despite attempts to improve services for women with complex needs, their negative experiences persist. Such experiences include ‘retelling their story multiple times’, feeling judged, having to answer personal questions without privacy and not feeling safe or listened to. These observations suggest that it is the services, rather than the women themselves, that can be challenging to engage with. Marshall (2021), recommends using support networks that promote togetherness and inclusivity, as benchmarks to nurture those who may experience vicarious trauma while supporting women in complex situations. Given the high value that women place on the support provided by volunteers, it is crucial to ensure that this type of support is consistently available across all criminal justice settings. This is particularly important given the negative impact of separation on women’s mental health and overall well-being.

Conclusions

The significance and value of the support provided by volunteer birth supporters and doulas to women experiencing disadvantage has been well-established in existing literature. Nevertheless, this study highlights the need for additional supervision and therapeutic support for those who may be exposed to traumatic events, such as witnessing the separation of an imprisoned mother from her newborn baby. Given that some organisations have already established effective models for providing a nurturing and supportive environment for birth supporters, it is recommended that these organisations are modelled as examples of best practice. By applying consistent standards across the third sector, organisations can retain birth supporters and properly recognise their altruistic contributions.

Acknowledgements

I am grateful to the Foundation for the Sociology of Health and Illness for funding the Mildred Blaxter postdoctoral fellowship and to Professor Hilary Thomas for her support and guidance throughout. The ESRC’s New Investigator grant also provided essential resources for this paper. Thanks to the Birth Supporters for their willingness to be interviewed and share their experiences candidly, and to the anonymous reviewers for their valuable feedback.

Disclosure statement

No potential conflict of interest was reported by the author.

Additional information

Funding

Foundation for the Sociology of Health and IllnessEconomic and Social Research Council (ESRC)