Nearly five months pregnant, Linda Acoff screamed in pain inside a cell in the Cuyahoga County Jail.
The pressure and cramping intensified. Blood specks dotting the cold floor were met only with a nurse’s offering of extra sanitary napkins and a dose of Tylenol.
Several more hours passed on that January 2024 morning before Acoff’s cellmate alerted a jailer, who looked inside before rushing to declare a medical emergency. Security video shows Acoff covering her anguished face as she’s taken out on a stretcher.
Left behind in the pregnancy pod cell were the remains of Acoff’s fetus, a girl lost at 17 weeks, according to the Cuyahoga County medical examiner, who also found Acoff had contracted an infection of the fluid and tissues inside her uterus.
Over a year later, Acoff grew emotional, struggling to understand why jail and medical personnel failed to provide immediate care.
“I was in pain, severe pain, and they did nothing about it,” Acoff said. “It is a traumatic experience. You don't receive the help that you need when I felt like they could have saved my baby.”
What happened to Acoff not only raises questions over prenatal healthcare for incarcerated women, but it also highlights systemic lapses in medical care more broadly in the county jail.
While the nurse in this case was fired, Acoff’s pregnancy loss and the outcomes of other pregnant women in jail aren’t tracked by Ohio.
The state requires county jails to report in-custody deaths, but there are no reporting standards for miscarriages or stillbirths in jails, a Marshall Project - Cleveland and News 5 Cleveland investigation has found.
Advocates and medical doctors call the lack of reporting for these failed pregnancies a blind spot for women’s healthcare behind bars.
Dr. Carolyn Sufrin, a board member of the National Commission on Correctional Health Care and a fellow of the American College of Obstetricians and Gynecologists, said it is essential to track pregnancy outcomes in jails.
“Women who don’t count, don’t get counted,” she said, “and women who don’t get counted, don’t count.”
‘A tragic event’
Acoff, 30, entered the Cuyahoga County Jail on Dec. 15, 2023, for a probation violation of failing to complete court-ordered mental health treatment. Acoff said she started to develop pain as soon as she entered the jail’s pregnancy pod.
On Jan. 7, jail records show a nurse visited Acoff in her cell for two minutes, offering the sanitary pads and Tylenol.
Her condition only worsened the next day, but Acoff said she received no more help.
“I was banging on the door for hours after I was bleeding on myself,” she said.
Cuyahoga County Medical Examiner Dr. Thomas Gilson ruled the pregnancy loss a “stillborn,” although Ohio law considers a stillbirth only after at least 20 weeks of gestation.
After being treated at MetroHealth Medical Center, jail officials released Acoff later that day on home detention.
Antoine Hare, Acoff’s boyfriend, teared up when discussing what she endured and how he envisioned being a father as a “blessing.”
The experience, coupled with her unanswered pleas for help, has left her traumatized, Hare said.
“She shouldn't have been treated like that,” he said. “We’re human beings, so we’re supposed to get the proper medical care, period. No matter where we’re at.”
After Acoff’s release, internal emails show top jail leaders questioning the need to report the stillbirth to the state, while also answering a Cleveland.com reporter’s inquiry about the medical emergency.
On Jan. 9, 2024, investigator Paul Marich emailed jail wardens that the county would not be required to file a critical incident report about the stillbirth with the Ohio Bureau of Adult Detention, which oversees jails, because the fetus Acoff was carrying was not incarcerated.
“While this is a tragic event… [the state guideline] indicates that it must be an inmate,” Marich wrote in an email.
Based on the reporting rules, “... I do not believe (Acoff’s stillbirth) will attract media attention.”
On Jan. 12, 2024, Jennifer Ciaccia, a Cuyahoga County spokesperson, alerted numerous county officials that the journalist had asked about the “pregnancy loss” and had questions on medical training and jail protocols, email records show.
Ciaccia provided officials with a draft response, which said an incarcerated woman was receiving medical treatment in the jail’s pregnancy pod.
Top Cuyahoga County officials, including Sheriff Harold Pretel, then spent several hours crafting and editing a statement about Acoff’s treatment inside one of Ohio’s most-troubled jails.
Later, Ciaccia told the officials: “Quick update. They’re not running this story, but may want to do a larger piece on medical and postpartum services offered to women in custody. We can talk next week.”
‘Egregious performance failure’
MetroHealth Medical Center provides healthcare services inside the Cuyahoga County Jail.
From January 2022 through December 2024, the jail housed at least 305 women with known pregnancies. Of those, 16 women gave birth while incarcerated.
In those same three years, just one failed pregnancy was reported — Acoff’s, according to William Dube, a spokesperson for the MetroHealth Medical Center.
After a hospital internal investigation into Acoff’s medical care, officials fired a registered nurse and issued a written warning to another for failing to help Acoff, hospital records show.
The hospital investigation found that:
After speaking to Acoff about her health issues, Nurse Felicity White sent an email to the on-call physician instead of calling, because the doctor had already seen Acoff. She then went to lunch.
During the hospital investigation, White told officials she “immediately sent the patient out after communicating with the provider.” However, she explained, “there may have been a delay due to short staffing on the security side.”
Video footage showed White leave the floor for a break and return 20 minutes later. She waited more than an hour to call an ambulance for Acoff, records show. White was previously disciplined for similar performance delays with another patient.
White was terminated because her “lack of proper escalation is considered an “egregious performance failure.”
Michael Adams, a registered nurse who joined MetroHealth in 2022, received a written warning for failing to “complete work or perform duties” when he did not call a maternity doctor for Acoff or have her sent out for treatment.
White declined to comment. Adams could not be reached for comment.
A MetroHealth Medical Center spokesperson declined to comment on Acoff’s treatment, but said the hospital is “singularly committed to providing the highest quality patient care to all and is honored to provide dedicated medical services to patients in the Cuyahoga County Jail.”
Medical care provided inside the county jail has come under scrutiny in the past year amid claims of delayed treatment and mounting deaths.
The Marshall Project - Cleveland and News 5 Cleveland obtained hours of surveillance videos and thousands of pages of records as part of a yearlong investigation into multiple deaths at the jail.
In one case, two days after Acoff’s stillbirth, jailers were accused of ignoring a man’s pleas for medical help after he repeatedly complained about chest pains. He collapsed on the floor, and nine minutes passed before jail workers started CPR. The man later died.
In April 2024, the state placed the county on a corrective action plan for delaying treatment. Jail deaths involving incarcerated adults lead to investigations that can often end with jails being placed on corrective action plans when staff fail to provide proper medical care.
Calls for change, reporting requirements
In 2019, Sufrin, the National Commission on Correctional Health Care board member, helped author a national study that tracked pregnancy outcomes in U.S. prisons and five large jails. The study estimated that 55,000 pregnant women enter jails each year.
Sufrin said the lack of reporting requirements makes it impossible to know whether any of the country’s more than 3,000 jails are failing pregnant women. She said a stigma exists around people in the criminal justice system.
“Every pregnant woman's body and health matters,” Sufrin said. “If all of those pregnancies are affected by preterm births or stillbirths, or if they’re all normal, healthy babies, these are things that we need to know so that we can then invest in healthcare resources for our nation’s jails.”
In October, the U.S. Government Accountability Office issued a report that found the nation is facing a maternal health crisis because it incarcerates women at the highest rate in the world.
One key takeaway concluded: “There has been little research or data to date on maternal health in (prison and jail) settings, and there is a need for better data on women who are pregnant, outcomes of their pregnancies, and postpartum recovery while incarcerated.”
That same month, the Ohio Jail Advisory Board, which establishes standards and policies for jails across the state, held its quarterly meeting in Columbus.
The Ohio Department of Rehabilitation and Correction oversees the board, which is made up of state and local officials.
Minutes from the October 2024 meeting show that a state official briefly led a discussion on whether pregnancy outcomes should be reported to the state.
“Several parties asked questions and raised concerns about the timing, substance and process for making such reports. No consensus was reached,” according to the meeting minutes. “The matter was tabled for further discussion later.”
Gloria Rodgers, a former Summit County Council member serving on the advisory board, said the conversation lasted only minutes with minimal questions asked.
Rodgers, a longtime nurse, said she told the board that pregnancy outcomes in jails need to be counted.
“This is a medical issue. It should be required to be reported,” Rodgers recalled telling the board.
State prison officials declined to answer questions about the lack of reporting requirements for pregnancy losses.
Dr. Michael Baldonieri, an assistant professor of reproductive biology at the Case Western Reserve University School of Medicine, said the infection Acoff suffered is one of the more serious complications of pregnancy because it can quickly lead to the mother and baby getting sick.
Any woman complaining over several days about the symptoms should have raised alarms for medical staff, he said. Even at 17 weeks, there is some hope that Acoff’s pregnancy could have been saved if she had received proper medical care, he said.
“If there's early appropriate diagnosis and intervention, that baby can absolutely survive if the patient is treated promptly,” he said.
Baldonieri is also a member of the Ohio Pregnancy-Associated Mortality Review Committee, which was created in 2010 to develop interventions to reduce maternal mortality, particularly for pregnancy-related deaths.
Ohio should require county jails to report miscarriages and stillbirths, he said, so overall trends can be tracked to improve mortality rates and pregnancy outcomes.
“If we’re not looking for problems, if we’re not aware of problems, they’re not going to be found,” Baldonieri said.