How one Emory nurse educator is helping prison moms fight opioid addiction

Brenda Baker is an RN and a CNS. She's also earned a PhD, teaches at a nursing college and has published numerous papers on maternal and newborn topics. But when she enters the room to teach incarcerated women about prenatal care, she is not thinking about academics. She's far more intent on creating an atmosphere where pregnant prisoners can feel safe and dignified. "If I show these women kindness and respect, maybe when they're at a crossroad later and trying to make a decision, they will make a better choice," she says.

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Built on that foundation of simple dignity, Motherhood Beyond Bars helps pregnant women in Georgia prisons have healthier babies – and maybe break a cycle of substance abuse disorder at the same time. "We see both sides," says Baker, an assistant professor at Emory University's Nell Hodgson Woodruff School of Nursing and research and program director for Motherhood Beyond Bars. "It's hard to see how they get treated, but then you can also see that they made bad choices. Often, they didn't really know a different way of life."

Motherhood Beyond Bars was formed in 2013 as the joint brainchild of Emory's graduate schools of Divinity, Public Health, Medicine and Nursing. Some are surprised to learn that the Georgia Department of Corrections is a full partner in the endeavor. But Baker says they are wonderfully supportive, particularly in providing consistent onsite visits from an obstetrician.

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"There's so much some of these women don't know about their bodies, even if they've already had other babies," Baker says. "A lot of them don't understand their menstrual cycles and they also have so many misconceptions about anything from contraception to birth and labor."

Pain control is a also a huge issue here. For some of the pregnant prisoners who are in recovery, "their greatest fear is to have a C-section and be exposed again," Baker says. "That fear goes beyond the prison population, to all women struggling with substance abuse. We know from science and from data that the first year postpartum is the greatest risk for relapse for women who've had a substance abuse disorder."

Motherhood Beyond Bars helps women used to using drugs to cope with stress to plan to navigate labor and delivery without them.

And they curb anxiety where they can, the same as nurses the world over. "These women don't get to take their family or a support system for their delivery," Baker notes. "And they're just like other women, afraid of pain and what might happen and wondering will their baby be safe."

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She's known her calling since childhood

Maybe it's not so surprising Baker is on the forefront of helping a population so susceptible to the nationwide opioid crisis. She says she comes from a long line of women who always seem to find the most vulnerable populations and work with them.

Baker grew up in the small Appalachian town of Christiansburg, Virginia. When her maternal grandmother died, she left behind journals written in the 1930s. "She wrote about being worried the kids at this little tiny school they all attended weren't being fed and how she organized the mothers and started a school lunch program as a totally volunteer effort," Baker says. Her grandmother signed up local businesses to donate food and the mother-volunteers cooked and delivered it so all the children had at least one healthy meal each day.

"Isn't that amazing, just to have that thought that you as an individual could do that?" Baker marvels. "And in those days it's not like they had cell phones or Sign Up Genius software to get it organized. Just themselves."

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Baker's mother worked in public health, basically as a volunteer. She was also a nurse, working nights at a tiny local hospital in the 1960s. "If Dad had to be away she would take us with her," Baker recalls fondly. "She'd put us to bed there, but you didn't have to stay in bed! I'd get up when she went to feed the babies in the nursery. I vividly remember how she wore a mask and held the babies. I'd watch and tell myself, 'That's what I'll do when I grow up, I'll take care of the babies!'"

That's exactly what she's done, working with newborn populations as a Neonatal ICU nurse and Labor & Delivery nurse. Then, at a point in her career when many would start slowing down, Baker earned her PhD at age 50 in 2011. She has now published research on many cutting-edge maternal topics, including "Social media as social support in the postpartum," published in 2018. Her review of literature published that same year in the Journal of Correctional Health Care has a direct bearing on her Motherhood Beyond Bars role.

She investigated perinatal outcomes of incarcerated pregnant women, describing the situations faced by the four percent of female inmates who face pregnancy behind bars. Baker's review determined that women who spent part of their pregnancy in incarceration tended to have longer gestation periods and their babies had higher birth weights, especially if the woman was incarcerated beginning in the first trimester. On the flip side, Baker's findings on incarcerated women's "maternal mental health well-being were inconclusive but suggest significant risk to maternal role development when mother and infant are separated," according to the abstract.

Part of the Motherhood Beyond Bars mission is improving this fragile bond between women who give birth while prisoners and their infants. It can be wrenching work. After delivery, incarcerated mothers have 48 hours before they return to prison and their infants stay behind.

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A nurse's role in overcoming the opioid crisis

Ultimately, Baker sees the experience of incarcerated females "intertwined" with the opioid crisis. "The odd thing about this dynamic is that if you are a known substance abuser, they will take your baby away," she says. "Women won't admit for that reason, and they don't go to prenatal care or get health treatment if they're scared of that."

Baker says the best way nurses can help is to look at dependence on chemicals as a medical issue. "We have to get beyond the shame and stigma associated with substance abuse disorder, recognize it for the disease it is and focus on ways to help the individuals affected by it," she says. "And on the whole we have to recognize that so many of the patients we care for have life trauma from abuse and living in violent communities. It influences their experience, their choices and how they interact with us in the hospital. We have to recognize that."

A key lesson she teaches incarcerated women is one more privileged women take for granted. "We would not doubt that we should ask if we have a question," Baker says. "But for this group, we have to tell them, 'You can ask!' whether it's your doctor or even during labor." The women are so enthusiastic about the "questions encouraged" approach that the curriculum is sometimes set aside while a question takes the group in a different direction.

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Those are inspiring and invigorating conversations. Others can be distressing, Baker says. "Some of the things they tell me about their lives, I just have to warn myself, 'Don't react to that!' I don't know how some of these women have survived their life experiences."

And there's been a learning curve, even though Baker is a mother of three and grandmother of one. "I've never been in a crack house," she says. "I don't know the vocabulary. What's an 8-ball? I learn things too."

One lesson she absorbed early on is confirmed each time she goes to the prison. "These women are kind to people," Baker says. "They've just had really hard lives."

Sometimes the women cry together, sometimes they laugh, like at the baby shower for all the pregnant prisoners who will deliver that month. They recycle the decorations and regulations require the shower gifts to be personal items for the women, like socks or shampoo, not cute little onesies. But the monthly event is a high point in the shared experience nonetheless.

"The women who are delivering that month pick the theme and the others decorate," Baker says. "They cut and color. In prison, the personal items are so important, because you have to have money in your account to buy in the commissary. So the women being honored are always very excited about what's in the bag of gifts!"

Sometimes a book group or church will sponsor the gathering or the gifts, sometimes some of the prison staff attends. "It's kind of fun," Baker says. "It's just a time to celebrate the mom and her baby."