Born in Chains: Perceptions of Brazilian Mothers Deprived of Freedom about Breastfeeding

Objective: To analyze the perception of mothers deprived of freedom about breastfeeding. Material and Methods: This cross-sectional study was developed in four prison units in the state of Paraíba, Brazil. The non-probabilistic type sample was composed of inmates who were breastfeeding. Information regarding mother, infant, prenatal care, breastfeeding and sucking habits were collected. Data were analyzed through the Statistical Package for Social Sciences and presented through descriptive statistics. Results: Of the 496 women under closed prison system, only 13 (2.6%) were breastfeeding their children in the prison environment. The age of mothers ranged from 19 to 35 years, and the most frequent age group was 19-23 years (46.2%). The majority had no partner (84.6%), low schooling (60%) and had other children (84.6%). All were pregnant when they were arrested and 76.9% underwent cesarean delivery. Infants aged 1-5 months and 61.5% were female. The majority of inmates performed prenatal care (76.9%), with prison being the referred site (60%). Participation in educational activities on breastfeeding was reported by 90.9%, and nurses were the health professionals who provided these guidelines (66.6%). Exclusive breastfeeding was reported by 69.2%, but the maximum period was two months (33.3%). All mothers complemented breastfeeding (100%). Nocturnal breastfeeding was reported by 15.4%, being used for the child to sleep. All children started bottle-feeding from the first trimester of life. Pacifier use was observed in all infants. Conclusion: Inmates are predominantly young, single, of low schooling and underwent cesarean delivery. Prenatal care was carried out at the prison and mothers participated in educational activities about breastfeeding. Exclusive breastfeeding was reported by the majority; however, the maximum time was two months. All infants used bottle and pacifier use was reported from birth.


Introduction
Breastfeeding provides numerous benefits for both infant and mother [1] and contains all properties necessary for the infant's healthy growth and development [2].The World Health Organization [3] and American Academy of Pediatrics (AAP) [4] recommend that infants should be exclusively breastfed from birth to 6 months of age.
Incarceration is the guarantee of withdrawal of individuals found guilty of illegal acts from society, imposing on them a situation of isolation and social reclusion and a disturbed and oppressive conviviality with other inmates amid the most varied types of pernicious influences [5].
In Brazil, 1.2% of incarcerated women are pregnant and 0.9% of them are breastfeeding [6].
Only 1% of female prisoners have children in their company and the length of stay with the mother in prison varies between four months and seven years of age [6].In African countries, female prisoners comprise between one percent (in Burkina Faso) and 6.3% (in Mozambique) of the total convicted population [7].In Canada, there are 30% more women in federal corrections now than 10 years ago [8].
In Brazil, persons deprived of their freedom in the prison system are those who have committed an offense over the age of 18 and who are temporarily under the custody of the Government, sentenced or in security measure [9,10].With the objective of providing comprehensive health care to these people, based on the principles of the Unified Health System and reorienting health practices in the penitentiary system, the National Health Plan in the Penitentiary System (PNSSP) was proposed.Subsequently, the National Policy on Attention to Women in Situation of Deprivation of Freedom and Former Inmates from the Prison System (PNAMPE) was instituted with the objective of reformulating practices of the Brazilian prison system, contributing to guarantee the rights of women, both Brazilians and foreign [11].
In order to assure mothers and newborns the minimum care conditions, Brazilian legislation, through Law No. 11.942 / 09, ensures the medical follow-up of women, especially before and after delivery.It also states that penal establishments for women will be endowed with nurseries, where female prisoners can take care of their children, including breastfeeding them for at least six (6) months [12].Thus, prenatal care includes actions to educate and prepare women for breastfeeding.The guidance provided by health professionals is essential for the outcome of good gestation, since doubts on the subject are clarified, making them more confident and prepared for gestation [13].Therefore, employees and health professionals who attend female prisoners in the puerperal pregnancy cycle should practice actions focused on promoting breastfeeding [13].
In the United States, because prison nursery programs are rare, the vast majority of incarcerated women will serve their sentences in a facility that does not allow infants to remain with their mothers [14].In Brazil, after delivery, incarcerated women must stay in a prison unit provided with nursery to breastfeed and care for their children for at least six months, and the unit must have nursery and health team ready to follow up and provide post-birth care for mother and child [12].Some factors may contribute to early weaning, such as pacifier use, lack of knowledge about the importance of breastfeeding, family influence, parity and socioeconomic conditions [5,15].Therefore, the establishment of a support network during the gestational and puerperal period becomes even more relevant in incarcerated women [5].
In view of the above, and due to the lack of similar studies in the dental literature, the present study aimed to analyze the perception of mothers deprived of freedom about breastfeeding.

Study Design
This is an observational, cross-sectional, descriptive study with quantitative approach.The research was developed in four prison units located in the municipalities of João Pessoa, Campina Grande, Patos and Cajazeiras, state of Paraíba, Brazil.The municipality of João Pessoa had adherence to the National Policy for Comprehensive Care to the Health of Persons Deprived of Freedom in the Prison System approved in 2015, with consequent implantation and qualification of the Health Team in the Prison System (ESP) previously registered in the National Registry System of Health Units.In Campina Grande, the Health Team in the Prison System of a male prison unit of the penitentiary complex, after agreeing with due administrative authorities, attends one day a week in the female penitentiary.The other units benefit from services offered by educational institutions of the private network that aim to train skills and competencies of undergraduate students for health care, in addition to being able to count on referrals for care in the care network of their respective municipalities.

Population and Sample
The study population comprised a total of 496 women in the closed prison system in four prisons.Mothers who gave birth before being arrested due to the occurrence of gestation and delivery occurred outside prison units were excluded [16].
Data were collected by two researchers, with information on mother (age, marital status, schooling, number of previous pregnancies and type of delivery), infant (sex and age), prenatal care (participation, educational action and professional involved), breastfeeding (exclusive breastfeeding and supplementation) and sucking habits (use of bottle and pacifier and time of use).

Results
Of the 496 women in the closed prison system, only 13 (2.6%) were breastfeeding their children in the prison environment.Maternal age ranged from 19 to 35 years, with mean of 25.4 years (± 5.1) and median of 27 years, and the most frequent age group was 19-23 years (46.2 %).
Most women do not have a partner (84.6%), have low schooling (60%) and have other children (84.6%).All were pregnant when they were arrested (100%) and 76.9% underwent cesarean delivery (Table 1).The majority of inmates performed prenatal care (76.9%), and the prison was the referred site (60%).Participation in educational activities on breastfeeding was reported by 90.9% of mothers, and nurses were the health professionals who provided these guidelines (66.6%) (Table 2).
The 13 children who lived with their mothers in the penitentiaries had between 1 and 5 months of life, with mean of 3.4 months (± 1.2) and median of 4 months and were mostly female (61.5%).
When questioned about exclusive breastfeeding, only 69.2% of mothers reported exclusive breastfeeding, but the exclusive breastfeeding period was two months at most (33.3%).At the time of data collection, mothers were complementing breastfeeding (100%).Nocturnal breastfeeding was reported by 15.4% of mothers, being used for the child to sleep.All children started bottle-feeding from the first trimester of life and used pacifier (Table 3).

Discussion
This study described the characteristics related to gestation and delivery and breastfeeding practices of women living with their children in prisons in the State of Paraíba, Brazil.The daily life of the female prison system portrays a denial of human specificities stemming from gender issues; among them, gestation, maternity, breastfeeding, self-esteem and sensitivity [5].
While in Brazil, the Federal Constitution establishes that female prisoners will be provided conditions to allow them to remain with their children during the breastfeeding period [17], in Zambia, incarcerated pregnant women described inadequate, i.e., it does not meet international standards, and in some cases, there is no prenatal care [18].However, despite changes observed in the regulatory framework of social protection policies for individuals, families and vulnerable populations, there are several examples of situations in which the physical and mental health of mothers and babies in the first six months have been excluded from primary care [2].
This study revealed that mothers are mostly young, single and of low schooling, confirming findings of other studies [5,13,16].Regarding the type of delivery, there was a predominance of cesarean delivery, different from that found in another study, where vaginal delivery prevailed [16].
Searching for the awareness of women and caregivers about the possible negative impacts of surgical intervention on mother and child is the best way to reduce cesarean delivery rates [19].Therefore, it is necessary to invest in the training of health professionals to enable them to perform prenatal care and follow-up, in addition to vaginal delivery, and to intervene with cesarean delivery whenever necessary, guaranteeing good practices and care humanization, as well as the promotion of safe birth and delivery [19].
Considering that most of these prisoners were pregnant during their involvement in crime, many are the points that deserve good judgment when it comes to women deprived of freedom, such as pregnancy, maternity and breastfeeding.The oral health care of pregnant women involves levels of care from the promotion, reception, and prevention to standardized clinical interventions [20].
One of the main ways of obtaining clarification about breastfeeding is through health education [5].The majority of inmates performed prenatal care, and the prison was the referred site.
The purpose of prenatal care is to follow-up pregnant women from the beginning of pregnancy until the end of gestation, helping as a moment of learning for the future mother, as well as preventing, identifying or correcting possible fetal complications, and explaining the pregnant woman about pregnancy, childbirth, puerperium and care for the newborn, ensuring at the end of gestation the birth of a healthy child and the well-being of mother and infant [13].
Knowing the aspects related to the practice of breastfeeding is a fundamental factor, so that the mother and the child can experience breastfeeding in an effective and calm way.During prenatal care, it is important to discuss the benefits of breastfeeding for women, children, family and the community, and to provide guidelines on breastfeeding management [21].
Mothers with support from their partners, family, and health care staff during prenatal care, which is an appropriate stage for educational action, are able to establish early relationships with their babies during pregnancy as they start having a place within the family [22].Therefore, the withdrawal from the family can generate total or partial absence of affective bonds, due to the unifying role played by the family [13].
Therefore, it is up to the health professional to identify and understand breastfeeding in the sociocultural and family context and, from this understanding, to assist the mother / baby binomial, including, whenever possible, their family, highlighting the importance of adopting healthy breastfeeding practices [23].In the prison context, the health professional must be prepared to provide effective, supportive, comprehensive and contextualized care, respecting the knowledge and life history of each individual to help overcoming fears, difficulties and insecurities [24].
It is also important to highlight how important it is to identify the knowledge, beliefs and attitudes that pregnant women have regarding breastfeeding, their previous experience about breastfeeding.For this reason, it is important to offer opportunities to exchange experiences through group meetings that aim to inform the advantages and the management to facilitate breastfeeding [21].
Almost all inmates had participated in educational activities on breastfeeding.According to inmates, nurses were the health professionals who provided these guidelines.For being the professional who is most concerned with caring for pregnant women during the pregnancy-puerperal cycle, and for taking important actions in health education programs during the prenatal period, the nurse has the possibility to prepare them for breastfeeding, making them aware of the correct practice [25,26].From the support of health professionals, mothers will have more knowledge about the importance of breastfeeding and may make a conscious choice between breastfeeding and not breastfeeding their children [5].The dentist is a professional who can be systematically involved in prenatal staff, contributing to improve the quality of care, especially in oral health education [20,26].
Promotion, protection and support of breastfeeding and healthy complementary feeding can be carried out in different contexts, with the involvement of all Primary Health Care professionals, whether at home or in the health unit, in consultations, visits or group activities.It involves actions of health education, clinical care of mother and baby, extended approach to cultural, psychosocial and family context [4,27].
Previous studies have shown that incarcerated mothers recognize the importance of breastfeeding, although their incarceration condition presents difficulties for this practice [13].In this study, only two-thirds of mothers had exclusive breastfeeding; however, the exclusive breastfeeding time was up to two months.Some authors have shown that there is no association between weaning and family income, marital status and maternal age [28].As the child's age increases, the likelihood of the introduction of other liquids and foods also increases [1], so that complementary foods should be introduced gradually, beginning around 6 months of age [4].When exclusive breastfeeding is not possible, breast milk -even the small amount of milk consumed in the first days of life-provides benefits [4,14].An analysis of studies conducted on three continents concluded that when children were not breastfed until the second year of life, they are nearly twice more likely of dying from infectious disease as compared to breastfed children [29].
The quality and duration of the breastfeeding process are related to the meaning that the woman attributes to this experience, considering the elements of interaction that she experiences in this context [5].Incarcerated pregnant women and nursing mothers find themselves in very peculiar and precarious situations, because it is an environment that does not provide security and tranquility, a fact that may interfere with the success of breastfeeding and the infant's growth and development [13].
The absence of breastfeeding from correction acts allows a status quo in which mothers are usually separated from their children and denied breastfeeding education and support, carceral budgets fail to include pumps and refrigeration, and there are inadequate provisions to ensure safe milk storage and transport [30].
Immediately after delivery, most mothers are discharged, returning to the penitentiary and experience postpartum without the presence of their partners, relatives or other persons in their relationship who could support them, which is fundamental for the exercise of their role as mothers [2].
The use of pacifiers is still a widespread cultural habit among Brazilian children [31].In this study, it was verified that all children used bottle and pacifier.The World Health Organization contraindicates the use of bottles and other nipples for their potential interference with optimal breastfeeding practices [32].The introduction of bottles and pacifiers, inadequate maternal nutrition, short breastfeeding period and with extensive intervals, the belief that breast milk is insufficient and lack of knowledge may interfere with breastfeeding duration, leading to early weaning [1,4,33,34].Exclusive breastfeeding up to six months of life can be considered a protective factor against the permanence of the pacifier sucking habit [35].
This study has some limitations, among them the fact of being cross-sectional, not being able to establish cause and effect relationships [15,36].In addition, mothers may not remind information previously received, so the lack of information about prenatal care can be attributed to memory bias [13].
This study reveals that mothers are not guaranteeing exclusive breastfeeding and, even if they enjoy the legal benefit that guarantees them minimum conditions of care, they are forced to introduce their child to an environment that is inadequate for their growth and development.
Therefore, it is necessary to establish legal criteria and / or sanctions for the enforcement of the right to breastfeeding when mothers are incarcerated or for early referral of their children to family members when the infant formula is early introduced.
Therefore, incarcerated pregnant women should be assisted by a multiprofessional health team to provide adequate information on the benefits of prenatal follow-up and exclusive breastfeeding.In addition, it is important that the dentist present in the Prison System Health Team advises mothers about good oral hygiene practices in their children, about the rational use of bottle and pacifier, providing information about signs and symptoms arising from the eruption of deciduous teeth.

Conclusion
Inmates are predominantly young, single, of low schooling and who underwent cesarean delivery.Prenatal care was carried out at the prison and mothers participated in educational activities on breastfeeding.Exclusive breastfeeding was reported by the majority; however, the maximum time was two months.All babies used bottle and pacifier use was reported from birth.
Data Analysis Data were analyzed using IBM SPSS Statistics for Windows Software, version 20 (IBM Corp., Armonk, NY, USA).Descriptive statistics were used to calculate the absolute and relative frequencies, mean, median and standard deviation.Ethical Aspects This research project was approved by the Ethics Research Committee of the State University of Paraíba (Protocol No. CAAE 64843317.0.0000.5187).

Table 2 . Distribution of mothers according to prenatal information and participation in educational actions related to breastfeeding.
*Could have more than one professional involved.