Mothers mothering in prison: an experience report of the nursing care project.

OBJECTIVES
to report the experience of designing and implementing the nursing care project with mothers and babies in prison.


METHODS
this is an experience report about the nursing care project with mothers and children in prison, having as a guiding axis Winnicottian concepts about the mother-baby relationship.


RESULTS
nursing consultations were held in childcare, thematic conversation circles and the manufacture of artifacts to encourage child development, as well as women's health care. The positive impact of the project has made it a health education program.


FINAL CONSIDERATIONS
elaborating the nursing care project encouraged other ways of providing care and implementing it, using Winnicottian concepts. It is recommended that training institutions consider the prison and the individuals there as a field in the learning process of health professionals.


INTRODUCTION
Infant mortality rates in Brazil have decreased sharply in recent decades. Even with this advance, in 2017, there was an increase of 4.19%, reaching 14.9 per 1,000 live births, 6.7% in the early neonatal period due to prematurity, congenital anomalies, birth asphyxia and neonatal sepsis (1)(2) .
Health promotion and prevention actions should begin in prenatal care so that delivery and the immediate puerperium occur in a healthy way. However, it will be unproductive if these health actions are restricted to only those moments. Therefore, it should be ensured that the mother and baby, during the first year, are priorities in health care, especially in the first six months, period of adaptation between both, with greater risk for difficulties of various orders (3) .
Growth and development are important indicators of the baby's health, which determines constant monitoring and intervention, when necessary, in order to promote the full potential of motherbaby. Among care, it is important to mention breastfeeding which, in addition to nutritional value, is the mother-baby relationship's founder, facilitating the acquisition and maintenance of a lifetime bond (4)(5) .
Development is a continuous process, and the baby is in the phase of absolute dependence, which determines that in order to grow, in addition to a satisfactory environment, a good enough mother is necessary, that is, that can meet the physical needs and emotional aspects of the baby (5) . The innate tendency to take care of the children is maternity, and the psychic availability is titled mothering (6) .
If maternity requires adaptations, the needs of the incarcerated woman are even greater, since she must also deal with the impact of being legally arrested and prevented from coming and going.
Considering the legal provisions guaranteeing human and children's rights, the Política Nacional de Atenção às Mulheres em Situação de Privação de Liberdade (freely translated as Brazilian National Care Policy for Women in Situation of Deprivation of Liberty) guarantees the permanence of the baby with the mother, for the minimum period of six months, so that they can breastfeed, including with spaces suitable for such (7) . However, it is not all the Brazilian states that comply with the legislation, and the mother and baby can be separated early or stay together, but in cells with inadequate conditions (8) .
The separation age between mother and child is an important factor for the consequences to come. From the age of two, the child's understanding broadens and she interacts with the situations around her. Thus, before two years of age, maternal deprivation can cause negative effects (5) . Thus, in the context of imprisonment, even for a limited time, both mother and child must take full advantage of this relationship.
The nursing professional, especially the nurse, can contribute to encourage the healthy relationship between mother and baby, considering that their training includes the vision of mother and baby, beyond the biological aspects, but as people who, in order to exist, need care and attention of another human being (5) .
Faced with these considerations based on Winicottian concepts (5,(9)(10)(11) , a nursing care project was developed with mothers and babies in prison. Thus, the objective of this study is to report the experience of elaborating and implementing the nursing care project with mothers and babies in prison.

Preparing the nursing care project for mothers and babies in prison
The lead author conducted a study that predicted the observation of women who were maternal in prison. The project was approved by the Research Ethics Committee of Penitentiary Administration Office of São Paulo State (REC-PAO-SP), according to Opinion 1.885.193.
Access to a penitentiary located in São Paulo States countryside occurred through contact with leaders, and the first visit took place during the Citizenship Day, when women under process of society reinsertion participate in educational lectures. It was possible to meet the Breastfeeding Ward, and talk to mothers who were very interested in topics about child health. This aroused both the head of the service and the researchers the idea of the nursing care project.
Therefore, in partnership with two nurses, authors of this report, the health education project for mothers and babies from zero to six months was developed. This project includes childcare nursing consultations, conversation circles and workshops for the development of artifacts for child development, with monthly frequency, being approved by the director of the penitentiary.
Sufficiently good mother, satisfactory environment and absolute dependence were already conceptualized earlier in the introduction of this article (5,9) . Relative dependence is when the baby does not totally need the mother, although it still depends on her. This concept is closely related to maladaptation, which is when the mother allows the baby to go. Disappointment is when the baby understands that he and his mother are different people. Play is the way the baby acquires internal and external experiences, and by acquiring them he achieves health (9)(10)(11) .

Establishing the nursing care Project
The project started on a monthly basis and subsequently became weekly, at the mothers. demand, with the consent of the prison director. It was organized inside the Breastfeeding Ward, in a disused room, a place for childcare nursing consultations, with stretcher, table and chairs.
Babies are monitored for growth and development in the primary care service of the municipality, being referred by prison security officers. However, the mothers do not follow up the babies, remaining without guidance to clarify the doubts regarding childcare.
Thus, childcare nursing consultations were conducted for guidance purposes, to clarify doubts, provide monitoring of growth and development, besides assessing through the mothers reports, how the mother-baby relationship was taking place, focusing on the Winnicottian concepts already mentioned. Nursing consultations in childcare followed the recommendations of the Ministry of Health (12) , with anthropometric assessment -weight and calculation of weight gain, length, head and chest circumference, and annotation of the parameters in the graphs, as well as vital signs (temperature, heart and respiratory rates) and assessment of development according to age frameworks, with concomitant explanation to mothers.
From the demands reported by the mothers, after the childcare nursing consultation, there were conversation wheels with themes of interest to them concerning the baby's growth and development; the importance of the child's booklet; encouraging the baby's senses of hearing and touch; sounds and speech encouragement; hydration; fever care; and child feeding. It is worth mentioning that these themes were recurring, since new mothers came to the Breastfeeding Ward at all times.
Especially in relation to development, conversation wheels reinforced the importance of the mother's care for the baby, as well as the significance of this care for both of them as unique individuals. Concerns emerged regarding concerns about the future separation of mother and baby, opportunities for nurses to discuss the importance of mother and baby preparation for this event.
The manufacture of artifacts to encourage child development made it possible for mothers to learn and also to wait for the consultation without interrupting the moment of care of other mothers. Toy production workshops such as mobiles and rattles, storybooks elaboration for babies, textures, and MDF (Medium-Density Fiberboard) and EVA (Ethylene-Vinyl Acetate) crafts were held.
Mothers received nursing care, such as blood pressure measurement, breast and surgical incision assessment -in cases of cesarean section. Also monthly, at the request of the direction of the penitentiary, and with the collaboration of a photographer, there were photo sessions to follow the babies. Later, the photos were delivered to the mothers.
Although there was no obligation to participate, there was no refusal in any of the proposed activities, 43 mothers and babies participated in the project within one year.

Resources
For nursing consultations in childcare, in addition to the furniture already described, we used a scale, anthropometer, tape measure, rattle, colored fitting pots, thermometer, stethoscope. For the workshops were used folders, cotton, cardboard, sandpaper, fabrics, felt, pens, paints, woods, resins, drawings and twine. These materials were acquired with their own resources, being made available by nurses who, at each meeting, took the ones that would be used, depending on the activity to be developed.
For materials use, there was a prior request to the prison management, and only the authorized materials were used, in compliance with the institutional security criteria. All materials were inspected on entry and exit according to safety standards established by the institution.

Impact of the nursing care project
The nursing care project was followed by the prison management and, after a year of implementation, considering the positive opinions of the women under process of society reinsertion, became a health education program.
Babies showed growth/development within the normal range. Only one needed follow-up due to low weight gain, with subsequent assessment in a specialized service, stabilizing over the months.
Mothers, whose babies had gastroesophageal reflux, reported concern with weight gain, being guided several times with the aid of the ascending growth curve, showing continuous growth.
Considering the link between women under process of society reinsertion and nurses (authors of this report), they asked for individual care to talk about the moment of separation between mother and child, when the woman gives her child to care of family or shelter institutions and ways to reduce maternal absence. At such times, Winnicotian concepts were essential to emphasize to mothers the importance of care they had been devoting to their children, since for many, though multiparous, this was their first mothering experience for their own life history that included drug addiction, unwanted pregnancy or even arrests.

FINAL CONSIDERATIONS
This study aimed to report the experience of designing and implementing the nursing care project with mothers and babies in prison.
Designing the nursing care project for mothers and babies in prison was important in encouraging other ways of providing nursing care against the background of a hostile and potentially unsafe environment. Establishment was crucial to understanding the various situations involving women/mothers deprived of their liberty.
Winnicottian concepts were very appropriate for the conduct of nursing care, mainly to emphasize the positive aspects of mothering and to reflect on the best environment for fulfilling the sentence when reeducation gives birth in the prison system, because the baby is sometimes imposed inappropriate environments and abrupt separations, without considering the emotional losses late. It is not a question of disregarding the reasons why women were imprisoned, but not forgetting that deprived babies need care.
Participating in the project made it possible to know the physical structure of a penitentiary, in particular, the Breastfeeding Ward where activities were developed and follow the routines of the institution, such as meal times, opening and closing of cells, professionals team routine, cleaning, and organization performed by mothers. The Breastfeeding Ward resembles a home, whose people relate to and experience moments of conflict and animosity, as well as affection and solidarity.
In this context, nursing care project activities made it possible to meet the demands of mothers and babies, bringing them closer to the beliefs and the reality they lived, instigating questions about the role of nurses in assisting incarcerated individuals and the impact that actions provide health.
Care for mothers and infants, in a comprehensive and humanized way, evidenced benefits to physical health, as identified problems were healed, and to mental health, bonding and the creation of an environment of emotional support.