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PROMOTION OF BREASTFEEDING IN THE PRISON SYSTEM FROM THE PERCEPTION OF INCARCERATED NURSING MOTHERS1 1 Aticle extracted from thesis Perception of nursing mothers on the promotion of breastfeeding in the prison system in the light of the structure of the open systems of Imogene King, presented to the Programa de Pos-Graduação em Enfermagem of the Univerisdade Federal de Pernambuco (UFPE), in 2015. This study was financed in part by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - Brasil (CAPES) - Finance Code 001

ABSTRACT

Objective:

to unveil the promotion of breastfeeding in the prison system from the perception of incarcerated nursing mothers, in the light of the structure of the open systems of Imogene King.

Method:

a qualitative study, developed in a female prison unit. Semi-structured interviews were carried out with 14 incarcerated nursing mothers, and the data analysis was guided by the Collective Subject Discourse technique.

Results:

seven central ideas grouped into each of King’s three open systems emerged: Personal System - The promotion of breastfeeding with a focus on the child’s health; Promotion of exclusive breastfeeding in an authoritative way; Interpersonal system - Conflicting interaction with health professionals; Harmonious and trustful relationship with the Psychosocial Sector; Social System: the rules of the prison system defining the duration of breastfeeding; Physical structure and confinement as stressors; The prison environment and its rules as generators of stress and disruption to the practice of breastfeeding.

Conclusion:

the promotion of breastfeeding in the prison is authoritative and denies the autonomy of the nursing mother to a conscious decision making. The prison organization has peculiar conditions that interfere both in the practice of breastfeeding and in the care to the nursing mothers, which leads to an inefficient interaction between women and health professionals, making it difficult to reach the goal of effective nursing care and satisfaction with the care provided.

DESCRIPTORS:
Breastfeeding; Prisons; Nursing; Nursing theory; Health education

RESUMO

Objetivo:

desvelar a promoção do aleitamento materno no sistema prisional a partir da percepção de nutrizes encarceradas, à luz da estrutura dos sistemas abertos de Imogene King.

Método:

estudo qualitativo, desenvolvido em unidade prisional feminina. Foram realizadas entrevistas semiestruturadas com 14 nutrizes encarceradas e a análise dos dados foi orientada pela técnica do Discurso do Sujeito Coletivo.

Resultados:

emergiram sete ideias centrais agrupadas a cada um dos três sistemas abertos de King: Sistema Pessoal - A promoção do Aleitamento Materno com foco na saúde da criança; Promoção do Aleitamento Materno Exclusivo de forma impositiva; Sistema Interpessoal - Interação conflituosa com os profissionais da saúde; Relação harmoniosa e de confiança com o Setor Psicossocial; Sistema Social: as regras do sistema prisional definindo a duração do Aleitamento Materno; Estrutura física e confinamento como estressores; O ambiente carcerário e suas regras como geradores de estresse e perturbação para a prática do aleitamento materno.

Conclusão:

a promoção do aleitamento materno no cárcere é impositiva e nega a autonomia da nutriz para a tomada de decisão consciente. A organização prisional possui condições peculiares que interferem tanto na prática da amamentação como na assistência à nutriz, o que leva a uma interação ineficiente entre mulheres e profissionais de saúde, dificultando, dessa forma, o alcance da meta do cuidado de enfermagem efetivo e da satisfação com a assistência prestada.

DESCRITORES:
Aleitamento materno; Prisões; Enfermagem; Teoria de enfermagem; Educação em saúde

RESUMEN

Objetivo:

desvelar la promoción de la lactancia materna en el sistema penitenciario a partir de la percepción de las madres encarceladas, a la luz de la estructura de los sistemas abiertos de Imogene King.

Método:

estudio cualitativo, desarrollado en unidad prisional femenina. Se realizaron entrevistas semiestructuradas con 14 madres lactantes encarceladas y el análisis de los datos se guió por la técnica del Discurso del Sujeto Colectivo.

Resultados:

surgieron siete ideas centrales agrupadas a cada uno de los tres sistemas abiertos de King: Sistema Personal - La promoción de la Lactancia Materna con foco en la salud del niño; Promoción de la Lactancia Materna Exclusivo de forma impositiva; Sistema Interpersonal - Interacción conflictiva con los profesionales de la salud; Relación armoniosa y de confianza con el Sector Psicosocial; Sistema Social: las reglas del sistema penitenciario definiendo la duración de la Lactancia Materna; Estructura física y confinamiento como estresores; El ambiente carcelario y sus reglas como generadores de estrés y perturbación para la práctica de la lactancia materna.

Conclusión:

la promoción de la lactancia materna en la prisión es impositiva y niega la autonomía de la madre que amamanta para la toma de decisión consciente. La organización prisional tiene condiciones peculiares que interfieren tanto en la práctica de la lactancia materna y en la asistencia a las madres lactantes, lo que lleva a una interacción ineficiente entre mujeres y profesionales de salud, dificultando de esa forma el alcance de la meta del cuidado de enfermería efectivo y de la satisfacción con la asistencia prestada.

DESCRIPTORES:
Lactancia materna; Prisiones; Enfermería; Teoría de enfermería; Educación en salud

INTRODUCTION

Brazil has the fourth largest prison population in the world. When considering only the female imprisonment, the country ranks fifth in the world, with a total of approximately 37,380 women incarcerated, which corresponds to 6.4% of the prison population. It should be highlighted that the absolute population of women in deprivation of liberty grew 567% between the years 2000 and 2014, while the male prison population growth was 220% in the same period.11 Ministério da Justiça (BR). Levantamento Nacional de Informações Penitenciárias - Infopen Mulheres 2014. Brasília (DF): Ministério da Justiça; 2015.

The prison system adopts an androcentric and sexist model, which disregards the specificities of gender and the diverse reality of men and women in situations of detention. The prison structure and policies were not considered regarding these specificities, but rather by men and for men. Incarcerated women make up a segment of this invisible population, in which their needs are neglected and their dignity constantly violated. In addition, they are excluded and stigmatized, because they experience the stigma of being women in a macho society and because they are criminals in an exclusionary society.22 Colombaroli CM, Braga AG. A cadeia feminina de Franca sob a ótica da visita íntima. Br J Empirical Legal Stud. 2014; 1(2):122-39.

In female incarceration, aspects inherent to motherhood need to be evaluated, such as guaranteeing the presence of the children with the mothers for the period established by law. With the purpose of guaranteeing favorable conditions for the permanence of these children in the prison system, it was published the Interministerial Ordinance No. 210, from January 16, 2014, which instituted the National Policy of Care to Women in Situation of Deprivation of Liberty and Leaving the Prison System (PNAMPE). This ratifies, among other issues, that female prison institutions have a specific place for pregnant and parturient women, nursery (space reserved for the stay of infants with their mothers, in order to promote breastfeeding (BF) and daycare for children over 6 months old and under 7 years old who are destitute. Also, it provides the minimum period of one and a half years for the woman to live with her child and breastfeed.33 Ministério da Justiça (BR) Portaria Interministerial nº. 210, de 16 de janeiro de 2014: institui a Política Nacional de Atenção às Mulheres em Situação de Privação de Liberdade e Egressas do Sistema Prisional e dá outras providências. Diário Oficial da República Federativa do Brasil, 17 Jan 2014. Seção1

In most of the Brazilian states, the pregnant woman is transferred in the third trimester to prison units that are suitable for the presence of mothers with their children, where they can stay with them for a period between 6 months and 6 years (majority between 6 months and 1 year). The children then leave the prison system, usually under the care of a maternal relative, and the mother returns to the prison unit of origin.44 Leal MC, Ayres BVS, Pereira APE, Sánchez AR, Larouzé B. Birth in prison: pregnancy and birth behind bars in Brazil. Ciênc Saúde Coletiva [Internet]. 2016 [cited 2017 Oct 26]; 21(7). Available from: http://www.redalyc.org/html/630/63046188008/
http://www.redalyc.org/html/630/63046188...

A study carried out in the United Kingdom evidenced an important emotional suffering of the incarcerated women who were separated of their children in the postnatal period.55 Abbott L, Scott T. Women's experiences of breastfeeding in prison. Midwifery Digest. 2017 Jun; 27(2):217-23.In contrast, another study also points to the importance of breastfeeding for these women who report a strong bonding with their child at that time.66 Abbott L. Becoming a mother in prison. Practicing Midwife. 2016; 19(9): 1-3

The practice of the BF has important aspects, which include the rights of mother and child, the community and humanity.77 Oliveira EF, Teixeira MC. O direito fundamental das presidiárias e seus filhos ao aleitamento materno. Rev Curso de Direito da Faculdade de Humanidades e Direito [Internet].2014[cited 2017 Oct 26]; 11(11). Available from: http://dx.doi.org/10.15603/2176-1094/rcd.v11n11p68-101
http://dx.doi.org/10.15603/2176-1094/rcd...
The right to breastfeeding is inherent in women in all circumstances, including those in deprivation of liberty. For this right to be guaranteed, there is the juridical-constitutional basis that values the effectiveness of this action, even if the reality is incoherent to the guarantee the specifics about the dignified breastfeeding in the prison.88 Soares EMC, Castro AED. Amamentação no cárcere: as entrelinhas para mães e filhos como sujeitos de Direito. Rev Âmbito Jurídico [Internet]. 2012[cited 2017 Oct 26]; 107(15). Available from: http://www.ambitojuridico.com.br/site/?n_link=revista_artigos_leitura&artigo id=12515
http://www.ambitojuridico.com.br/site/?n...

A study on the theme points to the scarcity of research and little practical experience on the support for breastfeeding women deprived of their liberty.99 Paynter MJ, Snelgrove-Clark E. Breastfeeding support from criminilized women in Canada. J Hum Lact [Internet]. 2017 Nov [cited 2017 Nov 26]; 33(4):672-6. Available from: https://doi.org/10.1177/0890334417726057
https://doi.org/10.1177/0890334417726057...
Therefore, it is considered important to know the perception of incarcerated nursing women about the promotion of BF in order to contribute to their psychosocial well-being and self-esteem. The understanding of the breastfeeding experiences and the perception of these women on the theme is relevant to guide the BF promotion activities for this vulnerable population.1010 Huang K, Atlas R, Parvez F. The significance of breastfeeding to incarcerated pregnant women: an exploratory study. Birth. 2012 Jun;39(2):145-55.

In order to understand the promotion of BF in prison, considering the particularities of incarcerated nursing mothers, this analysis was subsidized by the conceptual framework from which the Imogene King’s Goal Achievement Theory was derived. In the development of this framework, based on the general theory of systems, King identified three initial concepts: perception, interpersonal relations and organization.1111 King IM. King's conceptual framework and Theory of goal atteinment. In: Parker ME. Nursing Theories in Practice. New York (US): National League for Nursing; 1990. These would become the main representatives of each system belonging to the structure of the open systems of King.

In the structure of open systems, individuals are considered as a personal system, being understood by an individual in interaction with the environment. These individuals are able to act in small and large groups, which originates the interpersonal system, represented by individuals interacting with each other. Thesocial system is designated by the junction of groups with specific interests and needs, forming organizations and societies.1212 King IM. A Theory for nursing: systems, concepts, process. New York: (US) John Wiley; 1981.

Considering that the practice of BF is linked to a diversity of factors other than biological ones, running through economic, social, cultural and emotional dimensions, in addition to the interactions experienced by women in the social context in which they are inserted,1313 Santos EM, Agra GFA. Only the breast milk - meanings of mothers on exclusive breastfeeding. Semina Cienc Biol Saúde. 2016; 37(2): 93-106. it is understood the importance of understanding the promotion of BF in the prison from the perception of incarcerated nursing mothers, considering them as participants in the open systems structure. In this sense, the objective was to reveal the perception of nursing mothers about the promotion of BF in prison, in the light of the structure of the open systems of Imogene King.

METHOD

This is a descriptive and exploratory study with a qualitative approach. The study was developed in a Female Prison Unit located in Recife/PE, from July to October 2014. The study included all the nursing mothers who were deprived of their liberty who were with their children in BF and who were serving their sentences in a closed regime during the period of data collection, totaling 14 interviews.

The data collection was carried out through semi-structured interviews conducted by the following guiding questions: what is done to stimulate/encourage breastfeeding in prison? How is breastfeeding support in prison (provided)? What are the rules for breastfeeding in prison? What do you think of them? How is the relationship between the professionals and women during breastfeeding? How does the prison system interfere with breastfeeding? The instrument was submitted to a pilot test that verified its suitability for a satisfactory data collection, in order to reach the proposed objectives.

The interviews were conducted in a private room, inside the prison, in order to guarantee the privacy of the interviewee and reduce noise and interruptions. Only the nursing mother and the researcher were present, so that she could freely express her opinions, reducing the risks of break of confidentiality.

The data analysis was guided by the Discourse of the Collective Subject (DCS) technique, which consists of a strategy that proposes the rescue of collective thought in the investigation of what a group of people thinks about a certain subject. It is developed through the survey of the social representations and socially shared ideas.1414 Lefevre F, Lefevre AM. Curso teórico prático de introdução ao discurso do sujeito coletivo e ao software qualiquantisoft [Internet]. São Paulo (SP): IPDSC; 2012 [cited 2017 Oct 26]. Available from: http://xa.yimg.com/kq/groups/28001072/1072006145/name/2012APOSTILA%20DO%2017%20CURSO%20 DSC.pdf
http://xa.yimg.com/kq/groups/28001072/10...
The Qualiquantisoft® program was used as a systematizer resource for the analysis.

After the construction of the DCS, a comprehensive and interpretative analysis of the meanings emerged from the speeches of the participants, associating them to the explanatory model idealized from the structure of the open systems of Imogene King. Then, the researchers tried to verify if there was a logical correlation between them, corroborating the existing literature on the subject.

The research was initiated after approval by the Research Ethics Committee of the Federal University of Pernambuco (UFPE), Opinion Number: 674.23 (CAAE: 30982514.0.0000.5208), in accordance with Resolution 466/2012, which deals with the performance of research involving human beings. After clarifying all the doubts, the participants were invited to sign the Free and Informed Consent Term.

RESULTS

A total of 14 nursing mothers aged from 19 to 29 years old participated in the study. Of these, only four had high school, two were married and the others were single, 12 of them were still awaiting trial and the predominant motive for detention was drug trafficking. The detention time ranged from 1 month to 4 years. Two became pregnant in prison and the others were detained when pregnant and one in the puerperium. Only one of them had previous experience in breastfeeding in prison. The number of children ranged from 1 to 6, being 4 primiparous.

From the analysis of the interviews, seven central ideas (CI) emerged, which were grouped in each of the three open systems of Imogene King. Although there has been a division from the systems proposed by King, it is important to point out that none of them can be seen in isolation. The character of mutual interaction, in which all the systems influence and are influenced by the others, cannot be static, there are aspects of all the systems within each CI represented here. The flowchart shown in figure 1 represents the CI raised, influencing and being influenced by each other in the understanding of the promotion of BF in the prison.

Figure 1
Flowchart of the Central Ideas grouped within the Structure of Open Systems of Imogene King.

Personal System

The promotion of breastfeeding with a focus on the child’s health

The health of the baby being considered as the main reason for breastfeeding places the child as the core of the maternal behaviors.

Because here in the nursery there is more priority than the pavilion because of the children. For the pediatricians, it is necessary to give the breast. For them, children do not need anything else... just the breast. If the child gets sick, they say we should give milk because it heals a sick child faster... even more in a place like that, closed. Then we have to breastfeed so they do not get any diseases. (DSC1)

Promotion of exclusive breastfeeding in an authoritative way

The incarceration forces the woman to submit to the impositions of the organization that does not allow the entry of breast milk substitutes without a medical prescription. In addition, as a threat and punishment, they have the permanence of their child next to them conditioned to exclusive breastfeeding. If other milks are introduced without the express authorization of the institution, the child is abruptly withdrawn from the mother.

The collective discourse shown below portrays this imposition:

If you do not breastfeed, the child will go home; it is practically a psychological pressure, that if we cannot take it, the children go home. You cannot give them milk ... if they know they will send the child home. Only if the doctor authorizes and with the prescription. There are mothers who do not have milk, there is the pressure they impose, the mother worries more, then the milk dries more (DSC2).

Interpersonal System

Conflicting interaction with health professionals

The approach of health professionals to the incarcerated nursing mother has been centered on the biomedical model. It values only what is related to the biological body and, once again, to the curative medicine with a focus on children’s health.

They are always in their place and we are in ours. Usually they do not even ask about breastfeeding, only if the baby is well, they listen to the baby and that is it. For breastfeeding there is no one. The relationship they have with us for breastfeeding is to know if we are giving milk or not... just for that. Just the pediatrician comes, looks at the child very quickly and goes. Then we get stressed out (DSC3).

Harmonious and trustful relationship with the psychosocial sector

In contrast to the previous central idea, the nursing mothers showed great satisfaction with the care provided by the professionals of the psychosocial sector. This sector is comprised of psychologists and social workers and it is in constant interaction with women to provide psychosocial support in all aspects of the prison situation, including BF.

She does not oblige, but her group never gets empty, because she always talks in a nice manner, she always explains, gives proper attention. She says that breastfeeding is good... teaches how to apply massages, how to nurse a child, she always takes a doll, shows how it is... shows a video, DVD for us to watch. It is othe psychosocial sector that has this proximity to us, that has patience, because inside there is a lot of stress. They never came to measure the distance from us, not at all (DSC4).

Social System

The rules of the prison system defining the duration of breastfeeding

This study demonstrated that the prison organization allows the infant to remain with their mother only during the first 6 months of life.

We can only have the baby breastfeeding until the 6 months. It is a very bad thing to get separated from the child. I do not think it is right so because our kids are paying for something they did not do. I do not know how many months he will breastfeed... And then when he gets out on the street, he will have to have milk, or porridge, because I will not be with him to breastfeed. For me, he would nurse until he wanted to(DSC5).

Physical structure and confinement as stressors

According to the interviewees, although the referred institution has a space destined for mothers with their respective babies, isolated from the other inmates, this is below what is determined by the legislation. Unhealthy facilities, overcrowding and lack of playground denote an inadequacy of this space to the presence of children.

We have a lot of trouble to breastfeed here... because here is too bad, locks, confusion, people talking loudly around you... It is a lot of women... they keep fighting with each other. Space is getting smaller, because more and more inmates come... We do not have any more visits, sunbathing... you cannot go outside... here we feel more incarcerated than we already are. It has drips, there is no place for the newborn... For a nursery, to support the children and nursing mothers, it is very precarious (DSC6).

The prison environment and its rules as generators of stress and disruption to the practice of breastfeeding

The prison environment and its rules generate stress among the nursing mothers, in a way that it impairs the practice of BF in these establishments. The collective discourse evidences that the child becomes a tool of punishment and threat within the prison, when their presence is conditioned to the good behavior of the woman.

You have to be nice to be able to stay with the child... You cannot smoke, you cannot fight... The child cannot get sick, the son has to breastfeed... otherwise they send the child home... you have to stay away from your child... all this we think... So, I think all of this influences breastfeeding. Because they send the baby home and there is no way for the mother to breastfeed. And the mother to breastfeed, she has to be calm, calm... Otherwise the milk will not come out, and then I cannot stress over anything. But, the prison is theirs, you have to accept it (DSC7).

DISCUSSION

Personal System

Nursing mothers’ perception of the promotion of breastfeeding in prison

King conceptualizes the personal system as the interaction of the individual with the environment, in which that individual reacts to their expectations, perceptions and needs.1212 King IM. A Theory for nursing: systems, concepts, process. New York: (US) John Wiley; 1981. The perception is selective for each person, representing that each situation can be perceived differently by each one;1515 Evans CLS. Imogene King: A conceptual Framework for Nursing. California (US): SAGE Publications Inc; 1991. it involves the action taken by the individual in the present moment, besides being influenced by the education, expectations, self-concept and previous experiences of the individual.1212 King IM. A Theory for nursing: systems, concepts, process. New York: (US) John Wiley; 1981. In their reports, incarcerated nursing mothers perceive the promotion of the BF carried out in an authoritative way and focused on the health of the babies. In this way, little or no space is given to reveal the subjectivity of the nursing mothers, while their personal desires are subjugated to the needs of the children.1616 Kalil IR, Ferraz LMR, Aguiar AC. Da intenção ao gesto: aproximações e distanciamentos entre informações oficiais e percepções maternas sobre amamentação. Diálogos de la Comunicación [Internet]. 2014 [cited 2017 Oct 26]; (88). Available from: http://dialogosfelafacs.net/da-intencao-ao-gesto-aproximacoes-e-distanciamentos-entre-informacoes-oficiais-e-percepcoes-maternas-sobre-amamentacao/
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The World Health Organization (WHO), the United Nations Children’s Fund (UNICEF) and the Ministry of Health advocate the practice of BF for the promotion of health and satisfactory child development, which needs to be complemented from the 6th month of life and last until the 2 years or more.1717 Bomfim LTM, Novaes TF, Bonanato K, Navarro RS, Tedesco TK, Imparato JCP, Drugowick RM, Reis JB. Factors related to the practice of exclusive breastfeeding in different cities of the States Minas Gerais and Bahia, Brazil. Pesq Bras Odontoped Clin Integr [Internet]. 2017 [cited 2017 Oct 26]; 17(1):e3237. Available from: http://revista.uepb.edu.br/index.php/pboci/article/view/3237/pdf
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It constitutes inalienable right not only of the child, but also of the mother,1818 Ramos LS. Direito à amamentação e à convivência familiar: possibilidade de afeto e ressignificação do cárcere. Revista do Observatório Brasil da Igualdade de Gênero. Brasília (DF): Secretaria Especial de Políticas para as Mulheres; 2009. p.14-16. and it is linked to the idea of more health or health guaranteed by the best scientific evidence, to consider the complexity of the breastfeeding/weaning process and to value the role of the nursing mother as the protagonist of this experience.1616 Kalil IR, Ferraz LMR, Aguiar AC. Da intenção ao gesto: aproximações e distanciamentos entre informações oficiais e percepções maternas sobre amamentação. Diálogos de la Comunicación [Internet]. 2014 [cited 2017 Oct 26]; (88). Available from: http://dialogosfelafacs.net/da-intencao-ao-gesto-aproximacoes-e-distanciamentos-entre-informacoes-oficiais-e-percepcoes-maternas-sobre-amamentacao/
http://dialogosfelafacs.net/da-intencao-...

The supplementation with infant formulas, with no clinical indication, negatively affects the exclusive breastfeeding and is associated with a shorter duration of BF.1919 Niguyen T, Dennison BA, Fan W, Xu C, Birkhead GS. Variation in formula supplementation of breastfed newborn infants in New York Hospitals. Pediatrics [Internet]. 2017 Jul [cited 2017 Oct 26]; 140(1):pii:e20170142. Available from: https://doi.org/10.1542/peds.2017-0142
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As a strategy to protect breastfeeding, it is up to the prison unit to prioritize breast milk, discouraging the implementation of its substitutes during the first six months of life, reserving it for exceptional cases.1818 Ramos LS. Direito à amamentação e à convivência familiar: possibilidade de afeto e ressignificação do cárcere. Revista do Observatório Brasil da Igualdade de Gênero. Brasília (DF): Secretaria Especial de Políticas para as Mulheres; 2009. p.14-16.

However, this decision should be left to the nursing mother, since individuals have the right to participate in decisions that influence their life, health, and community services.1111 King IM. King's conceptual framework and Theory of goal atteinment. In: Parker ME. Nursing Theories in Practice. New York (US): National League for Nursing; 1990. Outside prisons, this woman retains her decision-making power over the introduction or not of formulas for her child.

The decision-making is an essential factor in the provision of nursing care,1515 Evans CLS. Imogene King: A conceptual Framework for Nursing. California (US): SAGE Publications Inc; 1991. since the participation in this process leads to a decrease in the resistance to the implementation of the intervention and learning occurs. By considering also the fact that those who make decisions are seen as having authority and power,1212 King IM. A Theory for nursing: systems, concepts, process. New York: (US) John Wiley; 1981. the possibility for the woman to decide on the establishment and maintenance of the BF in prison could lead to better adherence to the practice. This would promote BF within the perspective of the nursing mother’s autonomy and empowerment, with respect to the human dignity, giving women the power to decide on their own body.

Although the child-centered health promotion is a reality in life outside the prison, it is seen that it is even more pronounced within it, occurring according to the stigmatizing principle that these women would have lost the right to exercise maternity and, consequently, to breastfeed their children, due to the crime committed. Being reinforced that the only ones who deserve the benefits of breastfeeding would be the children who cannot be punished by the error that the mother committed.

Also, when determining mandatory exclusive breastfeeding, promoting the separation of mothers and children when this practice does not occur, the prison institution complies with the legislation that guarantees the child’s stay with the mother in the nursery for at least one year and a half, regardless of whether there is a possibility of breastfeeding or not.33 Ministério da Justiça (BR) Portaria Interministerial nº. 210, de 16 de janeiro de 2014: institui a Política Nacional de Atenção às Mulheres em Situação de Privação de Liberdade e Egressas do Sistema Prisional e dá outras providências. Diário Oficial da República Federativa do Brasil, 17 Jan 2014. Seção1,1818 Ramos LS. Direito à amamentação e à convivência familiar: possibilidade de afeto e ressignificação do cárcere. Revista do Observatório Brasil da Igualdade de Gênero. Brasília (DF): Secretaria Especial de Políticas para as Mulheres; 2009. p.14-16.

Interpersonal System

Interaction between incarcerated professionals and nursing mothers to promote breastfeeding

Considering the promotion of breastfeeding as a phenomenon in which the human relations can be determinant for their development, professionals and nursing mothers interact influenced by the perceptions, goals, needs and values of each one. In this process of interaction, health professionals have a responsibility to share information to help individuals make informed decisions about their health care.1111 King IM. King's conceptual framework and Theory of goal atteinment. In: Parker ME. Nursing Theories in Practice. New York (US): National League for Nursing; 1990.

There is a difference of social and moral character between two built categories of people, resulting in divergences in the perceptions of the self and of the other. Therefore, every prison organization indicates a profound difference between an employee and an inmate. When stigmatized and not stigmatized, they are in mutual presence, effecting the process of interaction, both sides will directly face the causes and effects of stigma.2020 Goffman E. Estigma: notas sobre a manipulação da identidade deteriorada. 4ªed. Rio de Janeiro (RJ): Livros Técnicos e Científicos; 1988.

Most prisons in Brazil do not provide full follow-up for the health of pregnant women. Educational activities in sexual and reproductive health should be provided to these women as health promotion strategies.44 Leal MC, Ayres BVS, Pereira APE, Sánchez AR, Larouzé B. Birth in prison: pregnancy and birth behind bars in Brazil. Ciênc Saúde Coletiva [Internet]. 2016 [cited 2017 Oct 26]; 21(7). Available from: http://www.redalyc.org/html/630/63046188008/
http://www.redalyc.org/html/630/63046188...
The absence of the Nursing in the actions of promotion of the BF in prison could be evidenced from the reports of the nursing mothers and the observation of the researcher in the place of study. Because it represents a profession of health care and education, this gap in the care of the incarcerated nursing mothers may indicate a denial of basic health rights for this woman and her child.

It is misleading to assume that all the nurses provide impartial and judgment-free nursing care. Their affective responses can be intensified and influenced by their attitudes and beliefs.2121 Hufft AG, Peternelj-Taylor C. Ethical care of pregnant adolescents in correctional settings. J Forensic Nurs [Internet]. 2008[cited 2017 Oct 26];4(2):94-6. Available from: https://doi.org/10.1111/j.1939-3938.2008.00015.x
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The belief that incarcerated people are dangerous, loaded with all the addictions and responsible for the greatest dangers2222 Foucault M. A microfísica do poder. Rio de Janeiro (RJ): Graal; 1979. may lead to segregation between health professionals and inmates, among women who would be worthy or not of quality health care.

This fact is worrying, since it is recognized that the nursing performance has the potential to reduce conflicts between scientific and popular knowledge through its attentive and comprehensive approach for assessing, directing actions and offering adequate support to the feelings of the nursing mothers, regarding beliefs, fears and insecurities. The role of the nurse is essential in promoting breastfeeding by adopting interventions that have a positive impact, such as counseling and puerperal visits, recognizing the social context in which the nursing mother is inserted.2323 Carvalho OMC, Silva KR, Andrade LZC, Silva VM, Lopes MVO. Prevalência dos diagnósticos de enfermagem de amamentação no binômio mãe-filho em Unidade Básica de Saúde. Rev Rene. 2014; 15(1):99-107.

The promotion of BF as described by the interviewees when referring to the care provided by the health professionals of the prison institution is centered on the biomedical model, which does not consider other aspects of the breastfeeding process, such as the social and cultural character of this experience. This reductionist model implies an instrumental view on the role of the mother-woman in society.1616 Kalil IR, Ferraz LMR, Aguiar AC. Da intenção ao gesto: aproximações e distanciamentos entre informações oficiais e percepções maternas sobre amamentação. Diálogos de la Comunicación [Internet]. 2014 [cited 2017 Oct 26]; (88). Available from: http://dialogosfelafacs.net/da-intencao-ao-gesto-aproximacoes-e-distanciamentos-entre-informacoes-oficiais-e-percepcoes-maternas-sobre-amamentacao/
http://dialogosfelafacs.net/da-intencao-...

Breastfeeding cannot be seen only by a biological and instinctive prism, since there are several nuances involved, which cannot be neglected. Cultural, anthropological, social, family, psycho-emotional, spiritual, among others aspects should be valued for the planning of promotion strategies. In this way, the nursing mother must be considered in her individual complexity, inserted in a certain culture and subject to the interferences of the environment in which she lives.

The adequate psychosocial support of the multidisciplinary team, combined with the quantity and quality of the information provided, is an essential tool for the reduction of the anxiety of the nursing woman. The creation of bonds, the maintenance of open dialogue, and the encouragement of the active participation of women during the pregnancy-puerperal cycle should be favored so that the promotion of the BF can be done with a stimulus to the practice, so that the puerpera feels safe and confident to breastfeed her child after childbirth. It should also be started during the prenatal care, be stimulated during hospitalization at the maternity hospital and be promoted during the puerperal follow-up.2424 Rodrigues AP, Padoin SMM, Guido LA, Lopes LFD. Pre-natal and puerperium factors that interfere on self-efficacy in breastfeeding. Esc Anna Nery [Internet]. 2014 [cited 2017 Oct 26]; 18(2). Available from: http://dx.doi.org/10.5935/1414-8145.20140037
http://dx.doi.org/10.5935/1414-8145.2014...

Health education must break with the biomedical model, of the body perception of a machine, and be directed to the dialogue and the socialization of knowledge and practices among users and professionals. The participation of women as protagonists in the decisions that involve their health has the potential to bring it closer to a proposal to promote BF as a right, in which autonomy and self-responsibility are valued.2525 Guerreiro EM, Rodrigues DP, Queiroz ABA, Ferreira AM. Educação em saúde no ciclo gravídico-puerperal: sentidos atribuídos por puérperas. Rev Bras Enferm. 2014; 67(1):13-21.

Knowledge about the concept of organization is essential for the professionals inserted in social systems. In order to work professionally and meet quality standards of care, these should exert influence in an organization.1212 King IM. A Theory for nursing: systems, concepts, process. New York: (US) John Wiley; 1981. When they act in a way that minimizes the effects that the prison organization brings to the nursing mothers, as evidenced in the discourses concerning professionals in the psychosocial sector, there is a decrease in stress and a strengthening of their decision-making power. This fact can lead to greater satisfaction with the care provided, having a greater potential to promote BF in the molds proposed by this study.

Social System

Interference of the prison organization in the promotion of breastfeeding

Organizations shape individuals in different ways to develop the achievement of organizational goals.1212 King IM. A Theory for nursing: systems, concepts, process. New York: (US) John Wiley; 1981. In the meantime, the prison organization uses a set of rules that show the main demands regarding the conduct the inmate in order to unbalance their needs and objectives, when they are submitted to sanctions, violating their autonomy.2626 Goffman E. Manicômios, prisões e conventos. São Paulo (SP): Editora Perspectiva; 2001.

Breastfeeding should be understood as an act that has physical and psychological repercussions and, therefore, should be treated as a priority in the prison system. In addition, the continuity of the bond should be privileged in this environment, in all situations. For this reason, the permanence of children with mothers in prisons must be guaranteed for at least 1 year and 6 months, since the maternal presence is fundamental in the period of development of the child, specifically regarding the strengthening of the maternal bond and in establishing trust, optimism and courage. These aspects can be compromised if there is an early separation. It is also in this period that the psychological elaboration must take place for the separation and future re-encounter.33 Ministério da Justiça (BR) Portaria Interministerial nº. 210, de 16 de janeiro de 2014: institui a Política Nacional de Atenção às Mulheres em Situação de Privação de Liberdade e Egressas do Sistema Prisional e dá outras providências. Diário Oficial da República Federativa do Brasil, 17 Jan 2014. Seção1

The power exercised by the prison organization defines the duration of the BF and the presence of the child with the mother until the sixth month of life, to the detriment of the woman’s desire, the health of the child and the legislation that protects them. The vulnerability of the nursing mother regarding the prison system forces her to accept this determination and curtails her right to decide about her and her child’s health. In this case, the exercise of institutional power hampers the promotion of BF and configures another factor of stress for these women.

In order to ensure that these children remain in the prison environment, the female prisons should ensure a healthy place for child development in addition to a quality relationship between mother and child. To shelter children up to 2 years old, they must guarantee a nursery space, with a limit of up to four beds per room for mothers and their sons and daughters, equipped with bathrooms that support children’s baths, space for recreation area and opening to an outdoor area.33 Ministério da Justiça (BR) Portaria Interministerial nº. 210, de 16 de janeiro de 2014: institui a Política Nacional de Atenção às Mulheres em Situação de Privação de Liberdade e Egressas do Sistema Prisional e dá outras providências. Diário Oficial da República Federativa do Brasil, 17 Jan 2014. Seção1

The incarcerated woman will not satisfactorily exercise her nursing role if there are no adequate physical facilities. It the State’s job to play its role in improving the structure of prisons, especially regarding the construction of nurseries and kindergartens that aim at the practice of BF in order to guarantee the rights of women and children.77 Oliveira EF, Teixeira MC. O direito fundamental das presidiárias e seus filhos ao aleitamento materno. Rev Curso de Direito da Faculdade de Humanidades e Direito [Internet].2014[cited 2017 Oct 26]; 11(11). Available from: http://dx.doi.org/10.15603/2176-1094/rcd.v11n11p68-101
http://dx.doi.org/10.15603/2176-1094/rcd...

The concept of space exists within all cultures, but it is perceived differently by each individual and dependent on the situation. This perception can be distorted by stress, sensory overload, and deprivation.1212 King IM. A Theory for nursing: systems, concepts, process. New York: (US) John Wiley; 1981. According to the collective discourse, the feeling of confinement intensified by the permanence in the nursery, the excess of sensorial stimuli, and the inadequacy of the prison space to care for the child, perceived by the nursing mother, negatively interfere with the practice of BF in prison.

In addition, the staggered authority and strictly enforced regulations make the inmates distressed and apprehensive about the consequences of disobeying the rules. Punishments are represented by the temporary or permanent denial of privileges or by the denial of the right to try to obtain them.2626 Goffman E. Manicômios, prisões e conventos. São Paulo (SP): Editora Perspectiva; 2001.

Authority is the legitimate power given to a person by virtue of their role and position in a social system. It results, among other reasons, from a position that allows an individual to distribute rewards and sanctions, and depends on a reciprocal relationship between an individual exercising authority and an individual accepting authority. Power is a characteristic of authority. Through it, one or more people influence others in a given situation. In a social relationship, those who exercise power can control groups and organizations.1212 King IM. A Theory for nursing: systems, concepts, process. New York: (US) John Wiley; 1981. The prison institution has almost total power over detainees.2222 Foucault M. A microfísica do poder. Rio de Janeiro (RJ): Graal; 1979. The authority and power exercised by the prison system reflect a denial of the rights of women and children and hamper the promotion of BF in prison.

Depriving women and children of the right to breastfeeding, as well as the right to remain together, because they are incarcerated, is another way of punishing them. This punitive action hurts the principles of reasonableness and proportionality by preventing the child from being breastfed to their mother’s breast and receiving the best food, as well as the affection that the moment provides.77 Oliveira EF, Teixeira MC. O direito fundamental das presidiárias e seus filhos ao aleitamento materno. Rev Curso de Direito da Faculdade de Humanidades e Direito [Internet].2014[cited 2017 Oct 26]; 11(11). Available from: http://dx.doi.org/10.15603/2176-1094/rcd.v11n11p68-101
http://dx.doi.org/10.15603/2176-1094/rcd...

The questions raised here, according to the collective discourses, increase the level of stress among these women. It is known that an increase in stress reduces the ability to perceive events and make rational decisions.1212 King IM. A Theory for nursing: systems, concepts, process. New York: (US) John Wiley; 1981. This should then lead to a decrease in interactions and goal setting between nurse and client, in addition to the ineffectiveness of the nursing care.1515 Evans CLS. Imogene King: A conceptual Framework for Nursing. California (US): SAGE Publications Inc; 1991. It configures a great interference factor in the personal and interpersonal systems of the nursing mother, generating an imbalance between the three dynamic systems proposed by King.

Figure 2
Explanatory model of Imogene King’s open system structure imbalance, caused by the stressors inherent to the prison organization (social system), in the promotion of breastfeeding (adapted).1212 King IM. A Theory for nursing: systems, concepts, process. New York: (US) John Wiley; 1981.

In addition, stress triggered by the prison environment has the potential to interfere with the physiology of breastfeeding. A study developed with Latin women, which explored the association between anxiety, postpartum depression, oxytocin levels, and duration of BF, demonstrated that prenatal depression, postpartum depression and anxiety were significantly associated with the early cessation of breastfeeding, that is, before 2 months of age.2727 Lara-Cinisomo S, McKenney K, Di Florio A, Meltzer-Brody S. Associations between postpartum depression, breastfeeding, and oxytocin levels in Latina mothers. Breastfeed Med. 2017 Sep; 12(7):436-42.

Nurses can reduce clients’ stress by providing adequate and timely information; assessment of physiological changes; aid so that individuals and groups can articulate their concerns. In this way, it will facilitate the setting of goals as well as the alternative means to achieve them.1212 King IM. A Theory for nursing: systems, concepts, process. New York: (US) John Wiley; 1981.

The care provided by professionals and institutional routines have the potential to facilitate the practice of breastfeeding by adopting measures that aim at the continuous support to the nursing mother, in order to consider their particularities in the elaboration of strategies of promotion, protection and support to BF.28

It is considered as a limitation of the study the fact that it portrays the reality of a single Brazilian prison unit. Added to this is the limited number of similar publications, which reinforces the importance of researches with a deepening of the theme in the different prison units, in order to favor the implementation of strategies for their promotion that are consistent with the different national realities.

CONCLUSION

It is possible to verify the adequacy of the explanatory model proposed by King for the understanding of the promotion of BF in the prison from the perception of the incarcerated nursing mothers. It was evidenced that the prison organization (social system), through its peculiarities, both physical structure and its values, goals and rules, triggers the increase of the stress of the nursing mothers. These stressors interfere in their perception (personal system) and hinder their social interaction (interpersonal system). In addition, the authority exercised by the prison system decreases the power of decision of the nursing mother, and it may cause an increase in the resistance to the implementation of strategies for the promotion of breastfeeding. These facts demonstrate an ineffectiveness of the authoritative actions to promote BF in prison, since they do not reach the goal of promoting breastfeeding in its broader concept, even if the practice happens.

In contrast, when professionals act to achieve organizational goals, they can influence the organization in ways that minimize these stressors. In addition, quality and humanized care, free of prejudice, in order to reduce the distances imposed by stigma, seeking to recognize them as dignified citizens, regardless of the crime they committed, contributes to the reduction of stress and the breakdown of this cycle, rebalancing the systems.

Nursing has as a challenge to promote BF in the prison in an effective way, with a view to equipping the incarcerated nursing mother to make conscious decisions about her health and her child’s, obeying the restrictions imposed by the social system. Thus, there will be effective health care, satisfaction with the care provided and the achievement of the goal of promoting BF, without harming the principle of human dignity, adjusted to the particularities of life in prison.

It is necessary, therefore, the training of health professionals, especially the Nursing ones, in the scope of the promotion of BF in prisons, with a view to welcoming and enhancing women’s autonomy. Sensitizing them to the reality of the woman in deprivation of freedom, it is possible to contribute to the guarantee of the basic human rights and the maintenance of the dignity in prison.

  • 1
    Aticle extracted from thesis Perception of nursing mothers on the promotion of breastfeeding in the prison system in the light of the structure of the open systems of Imogene King, presented to the Programa de Pos-Graduação em Enfermagem of the Univerisdade Federal de Pernambuco (UFPE), in 2015. This study was financed in part by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - Brasil (CAPES) - Finance Code 001

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    » http://dx.doi.org/10.5935/1414-8145.20140037
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Publication Dates

  • Publication in this collection
    03 Dec 2018
  • Date of issue
    2018

History

  • Received
    08 May 2017
  • Accepted
    18 Dec 2017
Universidade Federal de Santa Catarina, Programa de Pós Graduação em Enfermagem Campus Universitário Trindade, 88040-970 Florianópolis - Santa Catarina - Brasil, Tel.: (55 48) 3721-4915 / (55 48) 3721-9043 - Florianópolis - SC - Brazil
E-mail: textoecontexto@contato.ufsc.br