This is the second article in Rewire’s Women, Incarcerated series. You can read the other pieces in the series that have been published so far here.

On the morning of September 11, 2011, Krystal Moore thought she was dying. Sharp pain stabbed at her stomach, so much so that she curled up into a fetal position on her bed. She didn’t know what was happening. Though she was pregnant, she was only six months along, not nearly ready to give birth.

She couldn’t simply call the family doctor. She was an inmate, serving time at the Jerome Combs Detention Center in Kankakee, Illinois, for smoking marijuana while on probation. But in the early hours of that Sunday morning, her pain was escalating quickly.

“I woke up hurting,” she told Rewire. “I tried to get in the shower, and I couldn’t.”

She asked to go the hospital. She had spoken to some other inmates, and she began to think she was having contractions. The pressure on her stomach was getting worse.

A guard telephoned the jail nurse, Ivetta Charee Sangster, to tell her that Moore was having stomach pains. Sangster was on duty that Sunday, though she wasn’t actually at the detention center, which, like many jails, doesn’t have full-time medical staff available, despite housing a sick and vulnerable population. Even if Sangster had been there, she was only a licensed practical nurse, a role that generally involves providing only very basic medical care, like taking a patient’s blood pressure or changing a bandage. She would not have been able to give Moore the urgent care she required for what had become a serious infection of her womb.

Sangster sounded irritated on the phone, according to the transcript of the call that later appeared in a lawsuit filed by Moore.

“Krystal Moore, she’s—in my opinion, a lot of times she’s full of shit,” Sangster told the guard. “You can go eyeball her and call me back if you want. She’s probably full of shit. But you can let her know that she can see the doctor tomorrow if she’d like.”

Our attempts to contact Sangster were unsuccessful.

By 2:30 that afternoon—at least eight hours since she first alerted guards to her pain—Moore began bleeding while sitting on a toilet. Screaming out of pain and fear, she was finally taken to a local hospital, but not before being forced to walk down the stairs from her cell to the ambulance, according to a court opinion from December 2013.

Moore was fully dilated by the time she arrived at the hospital, where she says she was shackled to the hospital bed. Then, around 5:20 p.m., she gave birth to twins. Had she been taken to hospital earlier, there was a possibility that the babies could have survived, according to an expert who provided evidence for the lawsuit. Instead, one baby lived for only a day; the other survived for 16 days.

“I remember it clear as yesterday. I think about my twins every day and every night. How would they be?” Moore said.

Moore’s case settled last year for $620,000, according to her lawyer. But in a five-month investigation, Rewire found that her story is not unique. After reviewing more than 200 legal cases, as well as the Human Rights Defense Center’s database of “Deaths in [Corrections Corporation of America] Custody,” Rewire identified at least a dozen instances of women experiencing miscarriages, stillbirths, and ectopic pregnancies in jails and prisons across the country, in circumstances that show a shocking lack of medical care from the professionals charged with providing it.

This number is most likely a dramatic under-representation of the problem. In addition to the shame and grief that many women feel at the loss of a pregnancy, incarcerated women often fear complaining about their miscarriages behind bars because they do not want to compromise ongoing cases or face retribution from jail or prison staff, according to community activists and researchers who work closely with incarcerated women.

To be sure, low-quality prenatal care is a symptom of the larger problem of poor medical care in corrections facilities in the United States, as has been documented in California, Arizona, and Florida and through thousands of lawsuits against prisons and the private contractors that sometimes run them.

Prison health services were so bad in the 1960s and 1970s that in 1976 the U.S. Supreme Court ruled that failure to provide appropriate medical care to prisoners amounted to a violation of the U.S. Constitution’s prohibition on cruel and unusual punishment. As a result, incarcerated people are the only group in the United States with a constitutional right to medical care.

But with the swelling number of women behind bars, the failure to provide prenatal care is becoming a major concern.

The cases we examined were strikingly similar to Moore’s: pregnant women waiting weeks to see doctors, nurses instructing women to take antibiotics for labor pains, and inmates miscarrying in toilets or on cell floors. Sangster’s comments would have fit into any of the cases that we read. Again and again, we saw women inmates in need of prenatal care ignored, silenced, and disbelieved.

“I feel like that jail done killed my kids,” said Moore. “I’ve been feeling that since the day I gave birth.”

Prenatal Care Is Crucial—and Missing—Behind Bars

At the end of 2012, there were more than 200,000 women in prisons and jails, comprising 9 percent of the nation’s incarcerated population. Based on current trends, the number of women behind bars is expected to grow.

The median age of women in state and federal prison is 34, and the majority of incarcerated women are of reproductive age, according to a study by the Bureau of Justice Statistics. Many women in prison have high-risk pregnancies, complicated by problems including poor nutrition, domestic violence, mental illness, and drug and alcohol abuse.

Poor prenatal care in corrections facilities is a grave concern, especially since those facilities have become one of the major providers of health care for marginalized communities, according to Brad Brockmann, executive director of the Center for Prisoner Health and Human Rights at the Miriam Hospital in Providence, Rhode Island, an affiliate of Brown University.

“For many of the individuals who come into the system, their first physical as adults is when they enter prison or jail, because prior to January 2014 Medicaid was not available to many, with only safety-net programs available in the community,” Brockmann said.

The quality of prenatal care provided by prisons or jails varies wildly between and within states, with most facilities providing very poor care, according to a 2010 review of state policies by the National Women’s Law Center and the Rebecca Project.

The survey graded all 50 states on their treatment of mothers behind bars. Thirty-eight states received a failing grade in the category of prenatal care. The researchers reported that 43 states do not require medical exams as part of prenatal care for women in confinement. Forty-eight states don’t offer pregnant women screening for HIV.

And this review only examined what states said their policies were; there were no on-site inspections. “Paper reviews are of limited value in a corrections context,” said Amy Fettig, senior staff counsel for the ACLU’s National Prison Project.

The reality is, no one is looking closely at what is happening in practice on a national scale when it comes to the care of incarcerated pregnant people, experts told Rewire.

For instance, there are no clear answers to some fundamental questions, such as how many women are pregnant during incarceration each year in the United States. A 2011 report by the American Congress of Obstetricians and Gynecologists put the number at 6 to 10 percent of incarcerated women, while a 2008 study by the Bureau of Justice Statistics estimated that between 4 and 5 percent of women admitted to state and federal prisons that year were pregnant.

There are also no comprehensive data for the number of pregnant women in jails, which typically house people prior to conviction or sentencing, or sometimes for immigration matters or for shorter sentences.

And there is simply no national picture of pregnancy outcomes—miscarriages, abortions, stillbirths, and live births—for incarcerated women, experts told us. The most recent data we could find came from 1998, when the Government Accountability Office reported that there were about 1,400 births in prisons that year.

Only two states require collection of data on pregnancy outcomes for incarcerated women—Delaware and Oregon, according to the Rebecca Project report. Delaware did not respond to our request for records, but Oregon provided information recorded about the only state prison that houses women, Coffee Creek Correctional Facility, between July 2012 and November 2014.

That data say there were 51 pregnant prisoners during that time, but give little insight into the type of care provided to these women, apart from the indication that some women were assessed to see whether their pregnancies were high-risk. Of these pregnancies, 37 resulted in births while incarcerated. Eleven women had c-sections, and three women’s labor was induced. There was one miscarriage and one abortion, and an additional four women returned a negative pregnancy test after earlier indicating that they were pregnant. At the time the data were provided, seven of the pregnant prisoners remained incarcerated, while at least two had been released prior to giving birth.

The data do not cover jails, which are governed separately by each of Oregon’s 36 different counties, according to Wendy Smith, a spokesperson with the state’s Health Services Administration.

Another data set comes from Texas, which tracks how many pregnant inmates are booked into county jails—last month, there were 382. A draft bill would require Texas jails to collect data on prenatal care, as well as the use of solitary confinement or restraints on pregnant inmates.

It’s therefore reasonable to imagine that thousands of women around the country are experiencing a wide range of pregnancy outcomes while in jails and prisons, with no oversight mechanism to track the care they receive.

But most states do not collect data on incarcerated pregnant woman, and there is no national set of data about prenatal care or pregnancy outcomes for incarcerated people.

Experts say this lack of national and local data is no coincidence.

“It’s one of the many areas where the lack of data points to the invisibility of incarcerated people, and specifically incarcerated women,” Tamar Kraft-Stolar, director of the Correctional Association of New York’s Women in Prison Project told Rewire.

Despite the lack of comprehensive national data, our investigation found that, with few exceptions, prenatal care in prisons and jails across the country is shockingly inadequate.

In addition to insufficient food and inappropriate living conditions for pregnant people, our research underlines what health experts and women’s rights advocates have said for years: Prisons and jails are among the most dangerous places to be while pregnant.

“A Near-Death Sentence” for Writing Bad Checks

For Laila Batts, poor prenatal care behind bars came close to ending her life.

In early January 2007, Batts was detained for ten days at the Elmwood Complex Women’s Facility, in Santa Clara, California, after writing a bad check to pay some bills.

Batts was in her first trimester of pregnancy the day she entered jail, and that night she began to experience spotting and severe cramping. For the next ten days, Batts complained to nurses about her pain.

By Monday, January 8, Batts told jail staff that she wanted to go to the hospital, because her condition was getting worse. Her request went unfulfilled. On January 9, a nurse saw Batts bleeding on the floor of her cell and complaining that her symptoms were getting dramatically worse, but the nurse did not send for emergency help. When Batts finally saw a doctor the next day, January 10, the doctor noted that she was suffering from an abnormal pregnancy, was at risk of an ectopic pregnancy, and required care, according to records produced in the lawsuit. But instead of providing that care, the doctor sent Batts back to her cell. Batts thought she was suffering a painful miscarriage.

“What started out as a request for modified community service in light of her pregnancy turned into a near-death sentence, bringing Ms. Batts within hours—perhaps minutes—of losing her life,” court filings said.

The day after she was released from jail, Batts woke in excruciating pain and was rushed by ambulance to the emergency room, where, she told Rewire, surgeons removed her ectopic pregnancy, as well as a fallopian tube. Ectopic pregnancies are extremely dangerous, and require immediate attention to avoid potential death of the pregnant person.

Batts settled her case, but declined to say how much she was awarded.

What is unusual in her lawsuit is that the complaint focused on the physical and mental pain that she endured. The vast majority of cases we examined focused on the loss of the fetus, not on the suffering of the pregnant woman, because the law tends to focus more on permanent losses—the death of a “viable” fetus—than on temporary pain experienced by the woman. For this reason, we found more cases involving stillbirths (a loss of pregnancy after 20 weeks’ gestation) than miscarriages, which occur prior to 20 weeks.

And because many miscarriages are difficult, if not impossible, to prevent, it is extremely difficult for women who have suffered them while incarcerated to prove any fault on the part of the authorities. This makes mistreatment of miscarriage tough to detect, with even grassroots community advocates struggling to identify where it has occurred.

Diana Claitor, executive director of the Texas Jail Project, says she usually doesn’t hear about a miscarriage from the woman who suffered it.

“Mostly we get a grandmother calling,” Claitor told Rewire. “The first call I got was an elderly Hispanic woman asking, ‘Is there any way we can get the body of our dead grandchild and put it in the family plot?’”

“Sanctity of Life in Texas Looks Like This”

Many of the cases of miscarriage or stillbirth we found occurred in states that have recently introduced laws that claim to protect fetuses, even at the expense of the woman bearing them.

For example, miscarriage in Texas is treated differently if it does not happen behind bars.

Last year, Dallas police swarmed a high school after a fetus was found in a toilet. They launched an investigation, reviewing video footage and interviewing teachers to find the “suspect.”

But two years earlier, no such attention was given to the case of Autumn Miller, who in the summer of 2012 miscarried into a toilet while serving a one-year sentence at the Dawson State Jail, also in Dallas.

Miller, who in pictures has light brown hair and a warm smile full of straight, white teeth, was already the mother of three children. She had entered the jail in February, after violating probation on a drug possession charge, not realizing she was pregnant.

Throughout May and June, Miller complained of cramps and fatigue, and requested a pregnancy test and Pap smear. She never received either from the jail.

On the night of June 14, Miller began bleeding, and experiencing pain so severe that she couldn’t walk, according to a lawsuit filed against the Corrections Corporation of America. Miller told guards she felt like she was having a baby.

Guards brought her to a medical unit where a nurse waited on a telescreen (like the jail in Kankakee, there was no full-time medical staff on-site). But Miller could barely explain what was happening before a guard turned off the screen, handed her a menstrual pad, and locked her in a segregated cell.

Screaming, Miller gave birth into a toilet. She was then handcuffed, shackled, and transported to the hospital separately from her newborn. Miller named the infant Gracie Robinson; she barely weighed a pound. Gracie died four days later.

“They had her locked in a cell down in the medical area, all by herself, when she was laboring, unbeknownst to her,” Miller’s lawyer, Paula Sweeney, told Rewire. “Then they couldn’t find the key to get the door open when it became apparent what was going on. Then, as she’s laying there on the cot, with blood everywhere, in terror and agony, the male guards start taking pictures with their cellphones.”

Miller’s case was settled in January 2014, and the facility that housed her has since been shut down because of budget cuts as well as increased scrutiny about what was going on behind the prison walls.

“Texas runs around bragging about the sanctity of human life, until you get a chance to see it in real life,” Miller’s lawyer told us. “Sanctity of life in Texas looks like this.”

No Role for Prosecutors in Prenatal Care

Experts have a wide range of recommendations to improve pregnancy care in prisons and jails, including laws that require tracking and reporting pregnancy outcomes, the elimination of solitary confinement for pregnant prisoners, and an increase in inmates’ access to OB-GYNs.

In Texas, a coalition of groups, including the Texas Jail Project and the ACLU of Texas, is pushing for a bill that would mandate tracking of prenatal care and treatment of pregnant prisoners in the state’s approximately 250 county jails.

The bill has caused unease among some women’s advocates, however, because of fears that gathering data on pregnant inmates could lead to more punitive action by the state.

“There is legitimate fear from legislators that are interested in doing this kind of tracking that those numbers will be used to punish pregnant women for drug use,” Mathew Simpson, policy strategist at the ACLU of Texas, told Rewire. “When it comes down to it, if we don’t know the birth outcomes, we can’t make an assessment of where the gaps are.”

The broader picture, however, is that jails and prisons are generally the wrong place to house pregnant women, given that they frequently lack the appropriate staff or facilities, and are fundamentally geared toward punishment, not care.

“Judges and prosecutors think that it’s a good idea to empower jail guards—whose job is to punish criminals—to give prenatal care,” Lynn Paltrow, the executive director of National Advocates for Pregnant Women, told Rewire. “There has to be a very clear consensus that there is no role for prosecutors to be involved in prenatal care.”