 Okay. So I would like to introduce our two speakers today. So we have Laura Abbott and Tanya Kappa. They are presenting pregnancy in prison partnership, international PIPPI, building a collaborative global network of best practice for and with women prisoners. Dr. Laura Abbott is an associate professor in research and at the University of Hera. I'm going to get this wrong again. Hera Fashir. A registered midwife and a senior fellow of the Higher Education Academy and a fellow of the Royal College of Midwives. Laura's doctorate examined the experiences of pregnant women in prison, the incarcerated pregnancy and ethnographic study of perinatal women in English prisons. Laura co-authored the birth charter for pregnant women in England and Wales published by birth companions in May 2016. Laura has contributed to the review of her Majesty's prison and probation services operational policies for prison staffing, managing and caring for all women experiencing prisoners. I suppose I should technically say his Majesty now, shouldn't I? More recently Laura and the co-funded pregnancy in prison partnership international with academics in Australia, New Zealand, Canada, the USA and the UK wide prisons midwife action group. A current ESRC funded research in partnership with the charity birth companions and their lived experience team includes experiences of women and the professional staff involved with a criminal justice system being separated for their babies. Dr. Tanya Kappa is an experienced academic and midwife with over 25 years of international clinical midwifery experience. Tanya commenced her midwifery career in London, the UK and has held a range of positions including several clinical leadership roles within tertiary maternity services, a freestanding birth centre and was the named midwife for a case slate of HIV positive women. Tanya migrated permanently to Australia in 2006 and has worked for CQU University Australia teaching into the midwifery program since 2015. Tanya is currently a senior lecturer and the head of course for the bachelor of midwifery graduate entry and is based in Queensland. So I'm going to hand it over to Laura first and I'm going to sit here in the background and enjoy. Lovely thanks so much Liz it's fantastic to be here and it's lovely to see so many people from around the world actually that's really what Pippi is about so Tanya and I are here representing Pippi there's I think there's 10 of us now in our pregnancy in prison international group and the reason we wanted to come together was because we really want to find solutions and work together to give best practice to pregnant women in prison and new mothers in prison. There are issues around the world and so many similarities that we wanted to found Pippi and we've been going for about just over nearly two years now and today we represent the whole of Pippi and we're going to be talking about pregnancy in prison and I will be starting and then I'll be handing over to Tanya who will be talking about more nuanced diet in prison. So what I wanted to start with what we wanted to start with today was really to talk about what we already know about pregnancy in prison and this is pretty much all around the world. We understand that many women who end up in the prison system are victims themselves. They often have survived awful childhoods many have suffered sexual abuse in childhood many women around 50% of women in prison that we meet are also victims and survivors of domestic violence and unsurprisingly these women will go on to misuse substances such as drugs and alcohol and we understand that around 80% of women in all of our prisons are suffering some form of mental illness and that is pretty global that we find and the thing is we also have found that many women will discover that they're pregnant on admission to prison so it's something that women might find as a shock and surprise. What we don't really know and what we don't have numbers of particularly well globally is that the numbers of pregnant women in prison and we think in the UK there are around 600 pregnant women in prison each year and around 100 babies born to women in prison and about 50% of those babies will stay with their mothers on a mother and baby unit but then again 50% will be separated and go into the community and so it's important to think of this in context of around the world because we do have differences in the numbers but very similar characteristics in the types of women that will end up in the criminal justice system. So these are, I know Lizzie kindly mentioned that are birth charters so there's a picture of the UK birth charter and that was developed in conjunction with women with lived experience who work with the charity birth companions in the UK and academics and midwives like myself we co-authored the birth charter and this sets out best practice for pregnancy and new motherhood in prison and one of the reasons that Tanya and I have got to know each other and become firm friends from across the time zones is that in Australia the birth charter was adapted and used for the women in Australian prisons having babies as well so if there's something that you want to find out more I'm sure Tanya and I will be very happy to share any resources that you might like and might need and might be useful for women in countries that you're working in as well. So my research, to give a little bit of background my research was undertaken in, started in 2012 it's for a doctorate in health research and I wanted to look specifically at pregnancy in prison they hadn't been very much done especially from the women's perspectives themselves a lot of the research that had been done had been for staff and staff opinions so it was important to hear what women had to say themselves and I was able to do some research in three different prisons in England and I spent around 10 months researching different prisons and really hanging around prisons and it was an ethnographic study so I really wanted to get the whole picture so I was able to interview women and staff so I interviewed 28 women for my research and 10 members of staff and I was very fortunate that women were very willing and very kind in coming forward and very very candid with their experiences and what I found overall that the system really isn't designed with pregnant women in prison, with pregnant women in mind I mean when we think about prison we don't tend to think about pregnancy it doesn't tend to be the front and foremost of our minds so the system really isn't designed very well and when it comes to pregnancy and what I found mainly was that all pregnant women because they're going in and out of prison more often than anyone else any other prisoners they go in and out for their scans they're going in and out for obstetric appointments most of the women that you meet in prison are high risk and they would feel intense shame just the fact that they were going into the hospital from prison they would be flanked by two prison officers usually they would be in chains, they'd be in handcuffs they'd feel the gaze of the public on them and feel very ashamed of feeling being watched and judged and bearing in mind the majority of women in our prisons are there for very short sentences for crimes that are non-violent it's particularly difficult in those situations where women would want to sort of shout out look I'm not a murderer, I'm just in here because I'm for short lifting or some more minor crime and would be feeling very ashamed women didn't get what they're entitled to in prison so they're entitled to things like having pregnancy packs for extra food they might be entitled to have extra mattresses and something I found particularly shocking was that women couldn't get breast pads now it seems quite a simple thing to us but when women have been separated from their babies they're lactating, they've got leaky boobs and they're having wet patches on their clothes and it was very humiliating and shaming for women I found that medication would be missed so for instance there's a quote here on this slide saying my mum had a brain hemorrhage through high blood pressure so that's why I'm worried with my high blood pressure they said I have to wait for confirmation from my doctor and this is an example of a woman who didn't have her medication it's not a seamless process so it stopped the woman came into prison she had to get all her medication re-prescribed again and we know how dangerous that is so particularly women who might be on antidepressants or even antipsychotics it would often take a little time to get them re-prescribed and what I really found and I will stand by this it really isn't a safe place for a healthcare and a midwifery perspective there's a lot in the news at the moment about cell birth especially from the UK there's a big inquest ongoing due to the shocking and terrible tragic death of a baby inside one of our prisons and we know that at night time there's no midwifery care we know that women are locked in their cells they often don't get their call bells answered and I found in my research that women were giving birth in their cells and particularly shocking one woman in my study gave birth to her breached baby 36 weeks and she wasn't able to get to hospital in time simply because nobody believed that she was in labour so there's a lot of work that needs to be done and needs to change but from a positive perspective from a midwifery perspective we can make a difference from my research I was able to get a lot of publicity particularly surrounding cell births and it caught the eye of politicians and made changes happen in policy it doesn't go far enough in my opinion we need to go further myself and birth companions and others gave evidence for our UK Joint Human Rights Committee and that's a parliamentary committee and it's particularly focused upon the cell births and women giving birth in cells and the unsafe practice of the unsafe practice of going on inside of our prisons so it's important that we carry on and use our voices midwifery to make changes happen and that's one of the reasons why PIPI exists we are a really strong global collaboration countries around the world and I think we have a really strong voice and we're pretty much we're quite embryonic in a way we haven't been going very long but we really are very passionate about making change happen for pregnant women in prison around the world and setting a very strong powerful voice for change and here's some more pictures we did have films but we weren't able to share these with you but if anyone ever wants to see more resources from us we're very happy to share these are just pictures from the House of the Parliament giving evidence for our Joint Human Rights Committee and this was all actioned and taken forward and eventually policy has changed and again it's quite slow but policy is changing we do now have far more women in prison as in our prisons we also have specialist prison officers who have special training to support pregnant women in prison however I still feel we haven't gone far enough and we still have a long way to go to make sure all the changes are actioned on the ground and then one big issue that came from my research and I know has come from other research around the world and something that's important about food and food in prisons is particularly gets a particularly bad name as you can imagine not much is spent on food but if you're pregnant the timeliness of food is really particularly awful if you're feeling sick or nauseous or you have heartburn and nearly all the women I spoke to in prison would talk about food and how they felt either hungry or thirsty or the water coming out of the same taps they were using to wash the hands in their cells also the types of the quality of food this was a particular issue for women and the fact that they would have to eat at times of the day that the prison dictated which doesn't work very well for pregnancy and this is a quote from one of the women that spoke to me and she said it's disgusting she said ham is like spam but a cheaper version like the packets of dog food it's disgusting it's vile you get boiled burgers and half the food is never cooked properly I'm surprised the whole jail hasn't got food poisoning I don't eat meat here it's not meat it's horrific it's disgusting I wouldn't feed it to my dog it's really bad and that is an example and so many women would say similar things about the food and what I'd love to do now is to hand over to the lovely Tanya who is going to talk about our next steps and what we've been doing with regards to our scoping review of the literature so I will mute myself now Tanya and I hope I'm keeping to the right time but it's lovely to hand over Laura thank you Laura yes so I am going to talk to you now about some work we've been doing as part of the Pippi group when we first got together we all brainstormed and sat around and talked about what we thought was really worthy of our focus initially and one of the main themes as Laura has just talked about was around the diet provided to women in prison who are pregnant or new mothers so we decided that we would undertake a scoping review of the literature to I guess better understand what is known about the diet that is provided for women in prison who are pregnant or new parents and it was a bit of a large project because there was a great deal of literature around but very little of it specifically focused on diet and the food policies etc so I will now talk through what we actually discovered so our overarching review question was is the diet offered to pregnant women in prison adequate so just to provide a bit of background we know that globally the number of women who are in prison and are pregnant is increasing but little is really understood about whether their additional dietary needs are being considered or met when they are in prison so I guess the other thing as Laura mentioned earlier on that we need to also bear in mind is that a lot of women that do enter prison who are pregnant will have complex health and social backgrounds and interestingly being incarcerated actually provides an opportunity for them to have health interventions and to actually have their nutritional needs met during pregnancy so whilst everywhere we look at information about what pregnant women should and shouldn't eat what we didn't really fully understand at that point was how those needs were being met in prison so we undertook our review of the literature and I've just provided a quick summary here of the findings we have actually submitted this paper for publication so we will share it once it's published which obviously will contain a lot more information about the methods but in summary we had a total of 16 papers that met the inclusion criteria for the review just to revive you with a bit of an idea of where the papers came from we had six from the USA, four from the UK three from Iran two from Canada and one from Australia most of them are half I should say five for literature reviews qualitative studies and then there are a couple of mixed methods quantitative studies two were policy analyses one was a multi component consultancy paper and one was a report so what we did we extracted the relevant data and we thematically analysed that we actually identified two main themes the first we called an inconsistent reality and the second we called influencing the appeal of food the first theme an inconsistent reality really I guess represented the clear disconnect between rhetoric and what was actually happening the reality of what was actually happening so whilst the majority of the 16 papers clearly acknowledged that the women did have additional nutritional requirements and they were often documented and were very broadly based upon the local government dietary guidelines but the way in which those policies and guidelines were actually being translated into the correctional setting was really rather inconsistent and this was something we identified that there was a clear need for some consistency around policy development and the way in which they are implemented across the various correctional settings so for example some of the papers that we identified talked about prisons that did absolutely have policies in place some of them were very very comprehensive but they were inconsistently followed and some prisons had absolutely no policies whatsoever and I think that became apparent was that there was a number of additional factors that really influenced the prison services ability to provide the healthy and nutritious food so often food wasn't seen as a priority particularly when prisons were facing financial cuts and budgetary constraints of course the rising costs of food were having significant issues too it impacts who there was still a real focus on the simple need to feed a very large population and each person was allocated a per head costing for meals and that did not actually increase for women that were pregnant or breastfeeding and it became clear that the cost of ingredients paid a really important role in the type of food and the amount of food that was available for pregnant women one really interesting finding was that a study spoke about prison officers who were interviewed about their beliefs around diet for pregnant women and a significant portion of the prison officers didn't believe that women who were pregnant should be given any additional food or different food to the greater prison population there were some prisons that routinely provided pregnant women with additional food or snacks although they were given a specific pregnancy pack or vouchers which they could then use to buy up more food but often the foods that were available for them to buy up weren't particularly healthy and they were often high in sugar and carbs and that type of thing so that often was a bit of a terror for some of the women and in some studies there were no additional offerings whatsoever for women there was no opportunity to buy up food or even to earn money to buy up food because they weren't allowed to work in the prison unless they were pregnant and as Laura mentioned we also had quite a few things around the quality of the food being stodgy either really over cooked and rubbery or under cooked and raw and the chickens and the various meats were actually cold inside and that put the women off eating those foods there's quite a lot of talk in the papers about supplements with vitamins and that was seen as a bit of a one size fits all remedy I guess they felt that if they gave the women a tablet they wouldn't need to worry about what they ate so that was quite a common finding across the papers interestingly women who had specific dietary needs whether that was for medical reasons, religious reasons they generally weren't catered for and women who had side effects from pregnancy nausea, vomiting you know pica or indigestion but they were simply not catered for so if a woman was nauseous and vomited she wasn't then giving any further meals which was interesting the other theme that popped up was around access to fluids as well so we know that women during pregnancy need to have plenty of oral intake but that was limited and as Laura said often the water wasn't appealing because it was coming from crusty taps or it was warm or discoloured the second theme was called influencing the appeal of food so this actually related to the way in which I guess being incarcerated removed the women's autonomy around what they chose to eat the quality of the food they ate, how much food they ate and how they could access snacks and water and milk and so on and of course where they were actually able to eat and of course this in turn then influenced the appeal and the social aspect of eating and drinking were often diminished so those interestingly again as Laura mentioned those who make up a lot of the pregnant population are women who may lack some degree of food literacy and they may have some distorted views around what is considered a healthy diet so for example fresh fruit and vegetables and healthy protein sources weren't often part of those women's pre-prison diet what came out of that really was that a lot of women actually ate a lot better when they were incarcerated than when they were actually on the outside so women who were serving longer sentences often had much better nutritional health during their pregnancy so the other thing that popped up a lot was how important it is to provide women with education around what they shouldn't shouldn't be eating but of course given what we know about the lack of autonomy the lack of choices the women despite being told you shouldn't eat sugar and you shouldn't eat too much of this and that they weren't actually able to obviously visualise the packaging for the food so being served so they felt I guess a sense of frustration that the information was being shared but they couldn't actually act upon that and the women spoke of being fed rather than being nourished when they ate their meals a lot of women who found the meals particularly unappealing they would find that it was repetitive every other day they were having the same thing they were being told when they could eat and when they couldn't eat and they often felt hungry and some even lost significant amounts of weight so as I mentioned earlier on there were concerns around the safety of food because it was often undercooked or overcooked and this generally meant that they were hungry because they didn't eat and then the lack of consistent access to snacks and drinks actually had a further knock-on effect for them as Laura also said the environment where they were eating was also a challenge so they would be given a mealtime that was very restricted there wasn't a great opportunity to sit and enjoy the food it had to be eaten very quickly so they could return to their cell or what they were doing but interestingly some of the women felt that they also were turned off the food because they were eating next to their toilet in their room and of course that had a negative impact on their appetite so the next slide is so what so we thought a bit about how the findings of our review are important for practice I guess going forward and the things that we need to consider as midwives and as care providers for women who are incarcerated during pregnancy so we know that women in prison do often have a range of complex health and social needs and therefore the opportunity we have as midwives or maternity care providers when women are incarcerated to provide them with a good balanced healthy diet and education support is an opportunity that we absolutely should be seizing and as I mentioned earlier on it is known that when a woman is serving a longer sentence often her nutritional status is much better which has a knock on effect for maternal and newborn outcomes that improves those and we must harness the opportunities that we have when women are in prison and are pregnant because we know that pregnancy is a time when a lot of women are most receptive to education support and are most likely to make significant changes and of course last but not least we have to I guess be aware of our important role that we play as advocates for women and we really need to work towards as we are as a group as a PPP group are doing improving and I guess standardising isn't quite the word but ensuring that prisons globally regardless of their geographical location are having policies in place and are actually adhering to them when they are providing diet to women in prison now the next couple of slides Laura there are references aren't they which there are other wordy slides but they are available I understand after if you want to look up the 16 papers that fell into our inclusion criteria just there and that's it from us Liz excellent and yes people once the video goes up onto YouTube and Facebook they'll be able to watch and stop and explore and copy down the links as well it's an area that we don't necessarily think about being an area for midwives to work in when you think about the pregnant because it's not a place that we quite often have students going to it's not a place that is spoken about it's one of those areas that is kind of not intentionally hush hush but I suppose it is but when you look at the prison populations and you look at the women and the socio-economic situations and the mental health issues that involve it's an area that we definitely need to be involved in okay so if we've got any questions from the audience so Celine has said what about childbirth time um yeah that's a really good question I'm also looking at other comments in the in the chat as well as from Margaret for example saying how important is about prison authorities understanding and I totally agree um and when it comes to when it comes to birth um it's it's like any other woman um except home is not home um home is a prison cell so when women go into labour in in prison they need to um go to and this is in the UK and Australia and the USA this is this is what's happening the women need to go and be transferred out into um the local hospital the problem that we have is we have gatekeepers and we have barriers so it's not as straightforward as just um opening a front door and getting a taxi getting on the bus or getting in a car you have to go through um security checks um and one of the one of the things that has been quite a big issue and one of the reasons why one in 10 women in the UK are giving birth in their prison cells is they're not being gotten out in time um often that might be that that that somebody is not necessarily believing that a woman is in labour um that if you haven't got a midwife there you've got people making decisions about women's um it's women's labour without having the special skills that we have so it's it's very complicated um and it's why we're campaigning to end sentencing of pregnant women in prison in in the UK at the moment um but you know what you what in an ideal world what happens is a woman um goes into labour and she is transferred usually um with a prison officer with her and into the local into the local hospital where she um labors and gives birth in a local hospital there um she may or may not have a supporter with her um it very much depends on on the situation that she's in but often she's left without a supporter we have birth companions in the UK where we may go and and and give her um support um but yes it's it's quite complex and quite complicated um I'm seeing Margaret saying are they still um shackled no they should not be shackled when no woman should be shackled in labour um it doesn't happen very often anymore but we still do hear of cases where a woman may be and and maybe in the post-natal period as well um she should not be transferred in labour in handcuffs um that is mandatory policy now that she shouldn't be um yep Celine's talking about human rights absolutely um and and that is why we took it to the Human Rights Committee um so yes there's so much that needs to be done and and it's it's great for us to have a global presence um um and also you know anyone that's wanting to join with us and to sort of support and campaign with us is fantastic too I don't know if you had anything to say Tanya I'll get off my soapbox I'm always on it so I'll get off for a minute no no Laura that that's fantastic um I'm just reading Bridget's presentation thank you yes um Bridget's another one of our PPT members it's quite often it's not your conference presentations that things that we should have thought about suddenly get put into our face and into our view and it's like I'd never thought of that before and now it's something like yeah we should be thinking about it so we do need passionate people like yourself and your team who do bring this to the forefront to make us think and to make us remember that there are women who are disadvantaged that we need to be caring for both in prison but also when they get out as well and their experiences if they're still being pregnant in prison are going to affect subsequent pregnancy journeys and birthing journeys in the in the future yeah and Celine's asking about midwifery care um yes um we do have midwives in our prisons and we do have specialist midwives and I think at the beginning I've talked about in the UK we have a prison midwives action group where we have prison midwives who come together and share best practice and also experiences and support each other because it's quite a difficult job working in a silo um and often sort of quite disjointed from the rest of the healthcare team in prison so um yeah we do have it again we don't have specialist midwives in all of our prisons and that's what we need um you know wherever women are giving birth we need midwives so um yes we're still arguing for that and until recently the word midwife didn't even exist in any of our policies here in the UK so we're doing a lot to change that as well so needing to make sure that we have a much stronger midwifery voice and presence in our prisons and for them to know that we are not going away which is really important and we're not so Camille do you want to say anything? I was just going to say Laura I think we're probably a little bit behind the UK here in Australia we don't have specific um prison midwives as such um generally women are transferred to the local hospital and are provided with care um from the midwives there but um what we have been doing at Seeker University where I work with my colleague Bridget we've actually been linking our midwifery students with incarcerated women and they have been um following their journey as a continuity of care experience as part of their midwifery education program and it has been a purely supportive relationship so the students don't access the women's you know correctional background it is purely they're there as a support person to provide them with you know the I guess that relationship and that's feeling of safety um during their pregnancy they see them at least four times they will ideally go to the hospital with them when they birth and then they will see them twice postnatally so we are I guess trying to change things and we are trying to prepare the midwives of the future for this role um but at the moment we are absolutely a little bit behind you Laura um and we don't have that specialist position and I know that in um one of your partners in this project is Annette Brialy who's the professor of midwifery that I have the joy of working with under depending which way you want to look at it um and we have got midwifery students actually going out on Monday to the second um our second lot of students going out onto a placement actually the third lot going to the to the prison so they're looking forward to it from the students health the primary health care the mental perinatal mental health they're looking at it from that broader concept um because when the students went there last time there were no pregnant women there but they got a chance to look at what else they do and how they kind of prepare and have a talk to it so it is great now we had a question about have you published anything along your journey so far where can they find it um we well Laura has published lots and lots of work from her PhD and then haven't you Laura did you want to talk about what you've been publishing yeah I mean we're writing together as Pippi um as as Tanya said our our diet paper is currently under review and we have lots and lots up our sleeve um lots of work to be getting on with um but yes if I mean I've I have written and so is Tanya you've you've got lots of publications as well so I think um it's quite I think the best thing to I mean there's um on this slide there's a lot of references so if you want to have a look at that but if you if you look up on google scanner any either of our names either Tanya's name or my name or any of the Pippi group actually at the front of the slide you'll find um lots and lots of work on um presidency in prison my latest paper is on midwifery care in English prison so you might find that particularly useful um that's quite current that's just been published this year in birth um I've got a couple more under review at the moment um but yes I think you know it's like having a voice in our academic journals but also you know presenting and also with our governments and just keeping keeping on that way but the publications are quite quite useful to to really see what the evidence is so if you if you look up our names you will definitely find them there um but also email either of us or any of the Pippi group we you know this is we we love talking about this we love actually anything um so if you want to get in contact please do um and we'll be really happy to share anything any resources anything with you so do do contact us as well um just going to plug our twitter page well Laura yes we have a user page don't we our Pippi page which um you can contact us via that too yes that's I think there's a few slides we had it on the the yeah it's Pippi on the last slide yeah on the first slide we've got our contacts