Promotion, protection and support for breastfeeding in prisons: a scoping review

This article aims to identify and map the actions to promote, protect and support breastfeeding that are carried out within the prison system. Scope review, whose searches were performed in the Latin American and Caribbean Health Sciences Literature and Nursing databases, Virtual Health Library, Medical Literature, Analysis, and Retrieval System Online, via PubMed, Scientific Electronic Library Online and the Capes Periodicals Portal. A total of 465 studies were obtained, 177 duplicates and 175 by title exclusion were removed, 56 articles were eliminated by abstract, and eight articles were not found. After selection and reading by the review team, 16 ar ticles were removed, thus constituting ten articles with relevant results for breastfeeding promotion in prison, 13 articles with important results for breastfeeding protection in prison, and ten articles with potential findings for breastfeeding support in prison. It is necessary to promote breastfeeding in prison with promotion, protection and support actions, because many children are still prevented from being breastfed soon after birth, which characterizes inequality in relation to the population in freedom.


introduction
In Brazil, the female population deprived of liberty increased 525% from 2000 to 2016, reaching an imprisonment rate of 55.4 for every group of 100,000 women over the age of 18 1 . According to the study by Leal et al, 90% of pregnant women deprived of their liberty in Brazil are already pregnant 2 .
As a result of the relevance of the subject, in 2010 the United Nations Assembly approved the Bangkok Rule for the treatment of women prisoners and non-custodial measures for women offenders recommending maternity care within prisons, affirming that these women have specific needs and that human rights must be guaranteed for them and their children 3 .
In Brazil, the National Policy for the Promotion, Protection, and Support of Breastfeeding is based on the principles of the Unified Health System (UHS), which comprises equity, integrality, and universality. Thus, the people who benefit from this policy cannot suffer discrimination for social, economic, geographical, religious option, or sexual orientation reasons 4 .
Despite the encouragement, the rate of Breastfeeding (BF) has been decreasing worldwide, and for countries to raise the rate, joint actions will be necessary to encourage breastfeeding and discourage infant formulas 5 , especially strategies for vulnerable groups, such as women deprived of their liberty, who need greater support to ensure breastfeeding in prison.
Therefore, the National Breastfeeding Policy encourages actions for promotion (educational campaigns, health education, in-service training, with continuing education); protection (institutional resources and laws that protect BF, such as tax incentives for companies for BF rooms, maternity and paternity leave; Brazilian Marketing Standards for Foods for Infants and Young Children, Nipples, Pacifiers and Feeding Bottles) and support (direct assistance to women, with consultation and support groups 4 . Thus, to protect women, pregnant and lactating women in Brazilian prisons, the National Policy for the Care of Women in Prison and Ex-prisoners (NPCWPE) 6 . However, women deprived of liberty, during pregnancy, childbirth, postpartum and puerperium; receive inferior and unequal care compared to women who are free 7 , requiring respect for human rights, especially in the restriction of BF in the prison space, with no reception and specialized space in many Brazilian prisons. Furthermore, the separation between mother and child is cited as barriers to the encouragement and maintenance of breastfeeding, contributing to early weaning and the decrease in the breastfeeding rate.
From this perspective, in order to understand breastfeeding within the penal system, there is a need to, scientifically deepen how breastfeeding occurs within this environment. Therefore, this article presents a theme of relevance to the phenomenon of breastfeeding in prisons.

Objective
To identify and map the actions to promote, protect and support breastfeeding carried out in the prison environment.

Type of study
The scoping review methodology was used, according to the JBI manual, which proposes to map concepts, clarify research areas, identify knowledge gaps and explore the breadth of the literature 8 .

Formulation of the research question
The review question was based on the use of the mnemonic PCC, being P for participants: puerperae and pregnant women; C for concepts: actions to promote, protect, and support breastfeeding; and C for context: prison system. Thus, the question was: what actions to promote, protect, and support breastfeeding are carried out in prisons?

Data source
The searches were conducted in October 2020 in the Latin American and Caribbean Literature on Health Sciences, Nursing Database, São Paulo State Health Secretariat Database, among others of the Virtual Health Library Regional Portal, and the Virtual Health Library Breastfeeding. As well as in the Medical Literature, Analysis, and Retrieval System Online, via PubMed, in the Scientific Electronic Library Online, in the Cape Periodical Portal, SCOPUS, and WOS. There was no time limit to extend the results.
In the Capes Periodicals Portal, we used the following databases: Web of Science (Clarivate Analytics), Scopus, Embase and Cumulative In-dex to Nursing and Allied Health Literature -Cinahl, Academic Search Premier; SocINDEX with Full Text, Applied Social Sciences Index & Abstracts, Education Resources Information Center; National Criminal Justice Reference Service Abstracts Database; Sociological Abstracts and American Psychological Association. We added a search of the Brazilian Digital Library of Theses and Dissertations of the Brazilian Institute of Information in Science and Technology, in the Google and Google Academic search tools.

Data selection
The terms were organized for the search strategies with quotation marks to establish the exact expression of the compound term and word order. And the Boolean operators OR for grouping of synonyms and AND for intersection of terms. The terms identified in the controlled vocabularies were: "Breastfeeding" OR "Lactancia Materna" OR Breastfeeding OR "Breastfeeding" OR "Alimentación al Pecho" OR Amamantamiento, "Breast Feeding" OR "Feeding, Breast" OR Breastfeeding, Prisons OR Prison OR "Penal Centers" OR "Social Rehabilitation Centers" OR Carcere* OR "Penal Institution" OR "Penal Institutions" OR Penitentiary OR Prison* OR Prison OR Reformatory* OR Prison OR "resocialization center" OR "penal center" OR "recovery center" OR "re-education center" OR "social reintegration center" OR reformatory OR "penal establishment" OR "penal colony" OR "agricultural colony" OR "penal complex" OR "public jail" OR "penal institute" OR "detention center" OR Prisoners OR prisoners OR Detention* OR Incarcerated* OR "Person Deprived of Liberty" OR "Persons Deprived of Liberty" OR "People Deprived of Liberty" OR "Incarcerated* OR "Detained population" OR "Persona Privada de Libertad" OR "Personas Encarceladas OR "People Deprived of Liberty" OR "Population Deprived of Liberty" OR Prisoner* OR Cautivo* OR Detenido* OR Detenidos OR "Persona Privada de Libertad" OR "Personas Encarceladas" OR "Personas Privadas de Libertad" OR Prisoner* OR Rehenes OR Prisiones OR "Centros Penales" OR "Centros de Readaptación Social" OR Carcele* OR "Instituciones Penales".
The selection was started by first reading the titles, followed by the abstracts, and, after the selection, the full text was read. Inclusion criteria were established: types of studies: review and original articles, letter to the editor, case study, and experience reports that contemplated the theme breastfeeding in the prison system, available in full text. Exclusion criteria: articles available only in abstract, as well as studies that did not contain legible information about the method, phenomenon of interest, context, sample size, and results that were not aligned with the objective of this review 8 .
The studies that were not available were requested from the librarian in charge of the Clementine University Hospital of the Federal University of Rio de Janeiro (HUCFF/UFRJ).

Data analysis and organization
The selected studies were observed regarding identification, authorship, year of publication, country, method, and BF actions. The Rayyan QCRI 0.0.1 software was used to organize the articles.

results
The results of the process of database searches, inclusions and exclusions can be seen in the PRISMA Flowchart ( Figure 1).
The 33 selected articles were critically analyzed in relation to actions to promote, protect and support breastfeeding, resulting in the synthesis of findings, which were summarized and categorized according to identification, authorship, year of publication, country, method and breastfeeding actions, according to the results (charts 1, 2, 3, 4). The articles were identified (ID) as A1, A2, A3, ... A33, in increasing order, according to the year, and inserted into categories, according to the relevance of the theme of discussion of results.
Ten articles were identified, with relevant results for breastfeeding promotion in prison, 13 articles for breastfeeding protection in prison, and ten for breastfeeding support in prison, which supported the discussion based on the categories presented below. Exclusion by text not found (n = 08) Studies that did not contain readable information on method = 04 Results that did not align with the objective of this review = 06 Did not have Context in the prison system = 06

Actions to promote breastfeeding at the national and international level, in the prison space
In order for breastfeeding to be successful, actions to promote breastfeeding are essential; not only for the benefit of the child, but also as a woman's right (A19) 27 . However, the lack of actions to promote breastfeeding can lead to early weaning in the prison environment 26 . Therefore, it is important that health professionals develop activities that promote and support breastfeeding in prison (A4, A5, A6, A11, A12, A17, A18, A19, A20, A29) 12,14,19,20,[26][27][28][29]37 , in order to provide conditions for lactating women deprived of their freedom to feel more secure when breastfeeding their children (A17) 25 .
The lack of knowledge about breastfeeding is recurrent in the studies (A4, A19), and the promotion of health education is urgent. Therefore, a trained multidisciplinary team is essential for the development of activities to promote breastfeeding (A4, A5, A11, A19, A20) 12,13,19,27,28 , for the valorization of citizenship and respect for integrality 12 , because the practice of breastfeeding, still, is not in fact perpetuated in the prison space, due to insufficient information and en-couragement for the practice (A18), increasing the vulnerability of women and children 26 . Thus, a professional as a health educator in the prison environment contributes with information that will motivate changes in habits about breastfeeding, influencing decisions that will impact the health of the woman and child 28 .
However, a study conducted in Ireland in 2016 corroborates authors 12,27,28 , which describes that, although there is a policy for the female prison population, the actions to promote breastfeeding do not exist and women deprived of freedom do not breastfeed in prison, because the health professionals' practices are focused on treatment and not on promotion. Thus, the activities to encourage breastfeeding and the benefits for the health of women and children do not occur 20 . There is a need for breastfeeding in the prison space, described in study A17, developed in 2018 in Canada, in which with the increase in the female prison population, the promotion of breastfeeding in prison becomes a positive activity and ensures benefits within the prison space 25 .
Another study conducted in the US (A29) in 2018 noted a large increase in people incarcerated in that country 37 , agreeing with the results of another survey (A17) 25 . With this, there is an increase in the population of pregnant and lac- tating women. However, the study points out that there is little research on breastfeeding in prison that reports the importance of promoting breastfeeding in the prison setting 37 , and the few studies found only reported on the benefits of breastfeeding for the child within the prison system 12,14,19,20,37 .
In another article (A6), developed in 2013, in a penitentiary in Ceará/BR, it was observed that most women deprived of liberty had previously breastfed, a positive factor for women, for having already experienced the practice of breastfeeding, however, inside the prison, these women were weakened, requiring health actions on breastfeeding developed by health professionals 14 . However, experience developed in the USA in 2011 (A11) shows that imprisonment is an important factor for public health, as it is a social determinant that interferes with the health of children under one year of age. Participants demonstrated very low rates at any time during breastfeeding. Therefore, the study suggested that health care providers need to support them to improve breastfeeding practice 19 .
In another study developed in a penal institution in New York/USA (A5) in 2013, it was observed that there are no educational works on breastfeeding or specific policies for this population, and that, during the prison period, the mother-baby bond is affected, as well as mental health and breastfeeding, which directly interferes with the health of the woman and the child. The authors pointed out that only nine prisons in the US allow mothers to breastfeed their babies. Therefore, most babies are separated from their mothers at birth, not being an option for the woman, with an absence of policies to support and encourage breastfeeding in the prison environment 13 .

National and international breastfeeding protection actions in the prison space
There are numerous obstacles for the protection of breastfeeding within the Brazilian prison space (A8, A9, A10, A13, A16, A21, A22, A23, A30). However, Brazil sets an example for protection, through legislations that protect breastfeeding in prison. Since 1984, with the Penal Execution Law; 1988, with the Brazilian Constitution; in 1990, with the Child and Adolescent Statute, means to guarantee breastfeeding are sought (A8) 16 .
Considerable progress occurred in 2011, when the right to house arrest for women who are pregnant, have disabled children and/or minors began 16 . And, with the creation in 2014 of the National Policy for the Care of Women in Detention and Prison Egresses, the expansion of the protection of women in breastfeeding in prison was promoted (A9) 17 . But, despite the various Brazilian norms, there are still fragilities in relation to guaranteeing the rights of these women and their children 17 .
As the violation of women's rights, in which there is ignorance on their part, even with the legal protection, as described in the study developed in a Mother and Child Unit of a penal institution in Pará/BR (A23) 31 . The relevance of the rules of the penal system is to protect breastfeeding in prison, however, these rules generate several stresses for women, because they are imposed and are considered barriers to successful breastfeeding (A22) 30 .
In order to protect breastfeeding in prison, an integrative literature review (A30) mentions that the Brazilian criminal justice system has well-defined laws and public policies, but they need to be responsive to the real needs of women and their children 38 . As observed in the study conducted in the databases of the STF, STJ and the Courts of Justice of Rio Grande do Sul, Paraná, São Paulo and Mato Grosso (A10), in 2015, referring to the databases of the Brazilian higher courts, the right to maternity was an invisible theme, forgetting that women deprived of liberty have rights as citizens 18 . These difficulties can be observed in the study conducted in Pará-Brazil (A23), in 2018, which describes impeditive situations for the practice of BF, with the absence of protection for women 31 .
This situation of obstacles could not happen, since the State has the duty to ensure respect for breastfeeding and protection in the prison system. A study conducted in the state of São Paulo (A21), in 2018, observed that women, when breastfeeding, had a feeling of protection towards their children, and breastfeeding was an act that aroused good emotions, consequently, women felt more valued when they were respected 31 .
Therefore, the Brazilian penal system, according to a study carried out in prison institutions in São Paulo/BR (A13), must protect and provide subsidies for the bond to remain not only with the mother and child, but also to be extended to family members and the community, understanding that breastfeeding can be a new perspective of change 21 It should be added that protection should be provided by the prison system, not only with laws, but with a differentiated pris-on environment, since the study (A16) highlights that prison is a stressful and often unhealthy environment, in which many women need to adapt to the rules of the penal institution in order to be able to stay with their children 24 .
In other legislation, such as in Canada, the study conducted in federal prisons (A24) in 2018 reported that while there are laws that guarantee some rights to prisoners, there is no legislation that addresses breastfeeding 32 . The authors confirm this information, in that in the Province of Manitoba, since 1998, there is a guarantee of the child living with the person deprived of liberty, but there is no evidence of a child in prison in the province of Manitoba 32 .
In Canada, there were nearly 5,000 incarcerated women and 5% of women in prison were pregnant. This population increased 66% from 2005 to 2014, even with this increase, few studies have been conducted to examine the impact of breastfeeding within the prison and penal institution. Punitive power supersedes health needs, as described by the authors of A28 36 . Thus, it is emphasized that Canadian prisons need to effectively implement policies that guarantee the effectiveness of women's and children's rights and the protection of AM, according to A24 and A28 32,36 .
Provincial prisons do not allow women to be with their children, but federal penal institutions have policies to assist women and children in prison. Thus, there is an urgent need for a unified implementation in Canadian prisons and a reference on the rights to breastfeed 36 .
On the African continent, the authors of article A31, 2020, report that Malawi's policies need to adapt to the needs of pregnant and breastfeeding women, as there are legislations for the treatment of women deprived of liberty in accordance with international rules, but there is no legislation to protect breastfeeding 39 .
In Mozambique, another African country, the right to breastfeed in prison is guaranteed, according to A25 in 2018 33 . The study carried out in the penitentiary in Ndlavela reports the existence of the penitentiary health care service, in addition to having the special penitentiary establishment for women deprived of freedom, which has the assistance in the puerperal pregnancy period and attends to children from zero to five years old. However, the authors 33 report that women and their children live in conditions of vulnerability.

National and international breastfeeding support actions in the prison space
In 2010, a Brazilian article (A2) reported that the penal system did not have adequate conditions for breastfeeding to occur in this environment. The lactating women showed some knowledge about the health benefits for the woman and child, but these same women felt insecure about breastfeeding, especially after the separation of the child from the mother 10 . The need for support has been demonstrated in several studies (A1, A2, A3, A7, A15, A26, A27, A32, A33) 9- 11,15,23,34,40,41 , for example, the study in a Women's Penal Colony in Recife/BR (A32), conducted in 2020, showed this obstacle regarding the support for breastfeeding in the prison system, by both professionals and family members 40 .
The lack of support is characteristic of vulnerable women, such as black women and those with unfavorable socioeconomic conditions, corroborating the statement of the need for family support for breastfeeding. Thus, women deprived of liberty are more exposed in the pregnant-puerperal period, since there is a potential shortage of health professionals and, when they have professionals, there is no activity to support breastfeeding (A26) (34) .
In England, in a penitentiary (A1), in 1996, women were imprisoned during childbirth and breastfeeding was not effective, inhibiting the human right and health of the child and the woman, as a respect for citizenship 9 . In the study (A3), the need for change in England was argued 11 , with the creation of a group of women doulas, which aimed to carry out a birth plan and birth monitoring, in addition to supporting and encouraging the practice of BF in prison. The doulas are strategies to support BF, as described by A3 and A27 11,35 .
Only six prisons in the UK have joint accommodation, which encourages separation of mother and child, as women's prisons are not equipped to support and encourage breastfeeding, according to the study in prisons in Wales (A14) 22 . Agreeing with this statement, A7, A15, A27, A32 15,23,34,40 say that support is paramount for successful breastfeeding.
In the United States, if a woman is in prison without day care, she is automatically separated from her child upon discharge from the hospital and unable to provide child care upon return to prison (A35), perpetuating important obstacles to breastfeeding. However, in a positive experience in a prison unit in the USA (A7), to support a woman in breastfeeding, a breastfeeding plan was developed, with the creation of a partnership with the health team, the lactating woman, the family members, and the unit, showing the possibility of promoting breastfeeding in a safe and effective way 15 .
Thus, it is necessary to support women in prison for the success of breastfeeding, in order to break through the system's obstacles and overcome the shortage of professionals, as well as the lack of a safe environment (A33) 41 .

Discussion
The increase in the female prison population has been occurring in several countries around the world, such as the USA, China, Russia, Brazil, Thailand, India, the Philippines, Vietnam, Indonesia, Mexico, Myanmar and Turkey, and others 5 . The Bangkok rules ensure respect for women deprived of their liberty, especially since many have vulnerabilities, most notably pregnant and lactating women, with access to health care 16,22,23,32 , since most of them have their pregnancy discovered inside the prison system, having an important portion without access to care during the pregnancy-puerperal cycle, with the lack of incentive and support for breastfeeding and the separation of the children after birth, which are part of the reality of many prisons around the world 22,24,27,34,35 .
The promotion of breastfeeding is an important strategy to ensure health and maintenance for children's growth and development, but, despite the numerous benefits for women and children, it is not yet a reality for women in the prison system, with the nurse as the professional who most assumes the responsibility and commitment for the promotion and support of breastfeeding in this environment 14,27 .
Among some of the barriers are the environment, the damaged bond, the absence of a multidisciplinary professional team, the guaranteed time for breastfeeding 10,12,14,24,27,28,30,35 , the disregard for the recommendations, on free demand mentioned by the WHO and the MH, enabling a greater chance of early weaning and effective factors for not breastfeeding in prison 42 . Thus, there is a need for the State to invest in the creation of specific spaces, such as breastfeeding rooms, with the participation of trained staff, in order to favor the promotion, protection and support of breastfeeding in prison 12,14,26,27 .
It is noteworthy that some countries, such as Ireland, Canada, USA, Mozambique, Malawi, and Brazil have laws and policies for breastfeeding in the prison system, but there is a lack of more effective actions to guarantee the rights of women and children. At this juncture, Brazil stands out for its various laws and policies to protect breastfeeding, including the right to breastfeed in house arrest 17 . However, an inequality is observed between what is determined in the Brazilian legislations and what is executed in the prison units, requiring the use of the legislative determinations for this effectiveness 14,25 .
In other countries such as Canada, Mozambique and Malawi, despite the existence of legislation for the population deprived of freedom, there is no legislation that guarantees breastfeeding within the penal institution, showing the need for the advancement of human rights within prisons, on the issue of women and children's rights to breastfeeding. However, in these same countries, when some women are allowed to stay with their babies, they receive the support of doulas, midwives, and some have the support of society, as is the model in England 11,22,25 . This was only possible with the sensibility of society and the State, because many women had this difficulty in England, and, with this support, a significant contribution was made to change this reality 11,12 . However, despite all efforts, there are still women being separated from their children, making it impossible for them to breastfeed 23 .
It is emphasized that breastfeeding is not only the woman's responsibility, but everyone's, managers, health professionals, safety, state and society 43,44 , in addition to the primordial support of the family, which guarantees more effective BF and a healthier population 45 . This reality must change in Brazil, especially due to the deficiencies of penal institutions, health and security professionals in guaranteeing the promotion, protection and support of BF 9,10, [33][34][35]39,40 .
Thus, the prison system needs to emphasize the WHO recommendations regarding breastfeeding and understand how a practice benefits the health of women, children, and society as a whole. Women's prisons around the world should ensure actions to promote, protect, and support breastfeeding. Breastfeeding in prisons is a right guaranteed internationally by the Bangkok Rules 3 , as a human right. However, penal institutions still lack the structural conditions to meet the needs of women and children for BF, thus, alternative measures must be created to reduce inequalities and the violation of rights.

Concluding remarks
The study identified and mapped the actions of promotion, protection, and support in the field of breastfeeding within the prison system, many of them nullifying the guarantee of the right of women and children who live in this environment.
Therefore, the actions need to be intensified, with support from the WHO and UNICEF, in addition to the efforts of health and safety professionals, managers, academia and society as a whole, since this is a relevant issue for women's and children's health.
Thus, breastfeeding in prison should favor actions of promotion, protection and support, since many children with mothers deprived of their liberty are still prevented from being breastfed soon after birth, which characterizes inequality in relation to the population in freedom.

Collaborations
All authors contributed equally to all stages of writing the article: design, data analysis and interpretation; writing, critical review and approval of the final version.

Supplementary material
This study is the result of the products of the Thesis entitled: Lactating women and the axiological understanding of breastfeeding in the prison space, Universidade Federal Fluminense. The data from the research carried out and defended is available in its entirety at the link: https://app. uff.br/riuff/handle/1/23807.