ABSTRACT

This research aims to analyze the breastfeeding experiences of incarcerated mothers in the prisons of the Spanish penitentiary system. Additionally, it explores whether these mothers have perceived practices related to obstetric violence during pregnancy, childbirth, and the postpartum period. An exploratory-descriptive study was conducted using a qualitative approach and a critical ethnographic method. Fieldwork, including participant observation and semi-structured interviews, was carried out between December 2021 and April 2022. The study involved 30 adult women from Africa, Europe, Eastern Europe, and Latin America, all serving sentences with their infants in Mother Units located in the Spanish cities of Alicante, Barcelona, Madrid, and Seville. The main findings highlight the need for penitentiary policies with a gender and feminist perspective. These policies should aim to eliminate severe inequalities and discriminations faced by incarcerated women while protecting the basic rights of both mothers and infants.

KEY WORDS:
Prisons; Breastfeeding; Obstetric Violence; Human Rights; Feminism; Intersectionality; Mental Health; Spain

INTRODUCTION

Neither women’s prisons nor the situation of incarcerated women in Spain were studied in depth until the late 1980s.¹1. Almeda E. Criminologías feministas, investigación y cárceles de mujeres en España. Papers. 2017;102(2):151-181. doi: 10.5565/rev/papers.2334.
https://doi.org/10.5565/rev/papers.2334.... ⁾ Until then, these issues were largely overlooked, resulting in a significant gap in the literature.

The issue of breastfeeding, however, has garnered interest from diverse perspectives, leading to the development of significant bodies of knowledge on motherhood and child-rearing.²2. Massó E. Una etnografía lactivista: la dignidad lactante a través de deseos y políticas. AIBR. Revista de Antropología Iberoamericana. 2015;10(2):231-257. doi: 10.11156/aibr.v10i2.68023.
https://doi.org/10.11156/aibr.v10i2.6802... Nevertheless, few studies have explored the connections between these issues. That is, little research exists on breastfeeding in the Spanish prison system, in contrast to cases like Brazil³3. Ribeiro SG, Lessa PRA, Martings MH, Nicolau AO, Fernandes AFC, Pinheiro AKB. Experiência do amamentar por mães privadas de liberdade: estudo exploratório descritivo. Enfermagem em Foco. 2013:4(2):84-87. doi: 10.21675/2357-707X.2013.v4.n2.532.
https://doi.org/10.21675/2357-707X.2013.... ^,44. Dalmácio LM, Cruz EJS, Cavalcante LIC. Percepções de mães encarceradas sobre o direito á amamentação no sistema prisional. Revista Brasileira de História & Ciências Sociais. 2014;6(11):54-72.^,55. Cavalcanti A, Cavalcanti G, Celino S, Corrêa R, Ramos R, Cavalcanti A. Born in Chains: Perceptions of Brazilian Mothers Deprived of Freedom about Breastfeeding. Pesquisa Brasileira em Odontopediatria e Clínica Integrada. 2018;18(1):1-11. doi: 10.4034/PBOCI.2018.181.69.
https://doi.org/10.4034/PBOCI.2018.181.6... ^,66. Guimarães ML, Guedes TG, Lima LS, Morais SCRV, Javorski M, Linhares FMP. Promotion of breastfeeding in the prison system from the perception of incarcerated nursing mothers. Texto & Contexto - Enfermagem. 2018;27(4):e3030017. doi: 10.1590/0104-07072018003030017.
https://doi.org/10.1590/0104-07072018003... ^,77. Mariano GJS, Silva IA. Significando o amamentar na prisão. Texto & Contexto - Enfermagem. 2018;27(4):e0590017. doi: 10.1590/0104-07072018000590017.
https://doi.org/10.1590/0104-07072018000... ^,88. Santos MV, Alves VH, Rodrigues DP, Vieira BDG, Marchiori GRS, Branco MBLR, Oliveira TR, Bonazzi VCAM. Breastfeeding booklet in prison institutions: initiative for promotion, protection and support. Revista Brasileira de Enfermagem. 2022;75(Supl 2):e20210214. doi: 10.1590/0034-7167-2021-0214.
https://doi.org/10.1590/0034-7167-2021-0... ^,99. Santos MV, Alves VH, Rodrigues DP, Tavares MR, Guerra JVV, Calandrini TSS, Marchiori GRS, Dulfe PAM. Promoção, proteção e apoio ao aleitamento materno no espaço prisional: uma scoping review. Ciência & Saúde Coletiva. 2022;27(7):2689-2702. doi: 10.1590/1413-81232022277.19432021.
https://doi.org/10.1590/1413-81232022277... ^,1010. Santos MV, Alves VH, Pereira AV, Vieira BDG, Rodrigues DP, Tavares MR, Calandrini TSS, Ferreira EA. The vital value of breastfeeding for imprisoned women. Texto & Contexto - Enfermagem. 2022;31:e20210455. doi: 10.1590/1980-265X-TCE-2021-0455en.
https://doi.org/10.1590/1980-265X-TCE-20... and the United States,¹¹11. Huang K, Atlas R, Parvez F. The significance of breastfeeding to incarcerated pregnant women: an exploratory study. Birth. 2012;39(2):145-155. doi: 10.1111/j.1523-536X.2012.00528.x.
https://doi.org/10.1111/j.1523-536X.2012... ^,1212. Shlafer RJ, Davis L, Hindt LA, Goshin LS, Gerrity E. Intention and initiation of breastfeeding among women who are incarcerated. Nursing for Women’s Health. 2018;22(1):64-78. doi: 10.1016/j.nwh.2017.12.004.
https://doi.org/10.1016/j.nwh.2017.12.00... ^,1313. Asiodu IV, Beal L, Sufrin C. Breastfeeding in incarcerated settings in the United States: A National Survey of Frequency and Policies. Breastfeeding Medicine. 2021;16(9):710-716. doi: 10.1089/bfm.2020.0410.
https://doi.org/10.1089/bfm.2020.0410... ^,1414. Wouk K, Piggott J, Towner Wright S, Palmquist AEL, Knittel A. Lactation support for people who are incarcerated: A systematic review. Breastfeeding Medicine. 2022;17(11):891-925. doi: 10.1089/bfm.2022.0138.
https://doi.org/10.1089/bfm.2022.0138... for instance.

Therefore, we have identified a critical gap in the literature regarding the views and experiences related to breastfeeding on the part of incarcerated women in Spain, with a particular emphasis on situations of obstetric violence in general. Such situations may negatively affect these women by interfering with or hindering breastfeeding, despite being recognized as a human right.

As presented in this article, our research on breastfeeding among incarcerated women constitutes - both methodologically and phenomenologically - the first instance of mothers being interviewed about breastfeeding within prison walls. More specifically, employing a qualitative and feminist approach, we have aimed to capture first hand their unique voices, narratives, and worries, and explore their possible traumatic experiences of obstetric violence in the first person.

History shows that the internal structures and dynamics of women’s prisons, as described by Almeda:

The incarceration of pregnant and postpartum women has been examined in numerous studies, revealing severe deficiencies in maternal and perinatal care and the inadequacy of facilities.¹⁶16. Fochi MCS, Higa R, Camisão AR, Turato ER, Lopes MHBM. Vivências de gestantes em situação de prisão. Revista Eletrônica de Enfermagem. 2017;19:1-10. doi: 10.5216/ree.v19.46647.
https://doi.org/10.5216/ree.v19.46647... ^,1717. Paynter MJ, Drake EK, Cassidy C, Snelgrove-Clarke E. Maternal health outcomes for incarcerated women: A scoping review. Journal of Clinical Nursing. 2019;28(11-12):2046-2060. doi: 10.1111/jocn.14837.
https://doi.org/10.1111/jocn.14837... ^,1818. Cross J. Imprisoning pregnant and parenting women: a focus on social justice, equal rights, and equality. Health & Social Work. 2020;45(3):195-201. doi: 10.1093/hsw/hlaa008.
https://doi.org/10.1093/hsw/hlaa008... ^,1919. Alves IC, Hordones L, Lopes LM. No cadeião não tem nada disso não: a percepção da saúde pelas internas do Centro de Referência à Gestante Privada de Liberdade. Revista Brasileira de Ciências Criminais. 2019;(162):345-382.^,2020. Friedman SH, Kaempf A, Kauffman S. The realities of pregnancy and mothering while incarcerated. The Journal of the American Academy of Psychiatry and the Law. 2020;48(3):365-375. doi: 10.29158/JAAPL.003924-20.
https://doi.org/10.29158/JAAPL.003924-20... In fact, both prisons and the studies about them are often based on assumptions that are both gender-neutral and universal, which in reality are tacitly and implicitly based on male experience. Therefore, prisons continue to

In 2016, the United Nations Human Rights Council²²22. United Nations. Joint statement by the UN Special Rapporteurs on the Right to Food, Right to Health, the Working Group on Discrimination against Women in law and in practice, and the Committee on the Rights of the Child in support of increased efforts to promote, support and protect breast-feeding [Internet]. 2016 [citado 10 mar 2023]. Disponible en: Disponible en: http://tinyurl.com/38eu26xn .
http://tinyurl.com/38eu26xn... recognized breastfeeding as a human right both for mothers and children that should be promoted and supported in all circumstances. Thus, there is a need to comprehend it based on a strong sense of universality with clear feminist connotations.²³23. Massó E. Human lactation in the anthropocene: a post-pandemic emergency. Medica Review. 2021;9(2):63-77. doi: 10.37467/gkarevmedica.v9.3125.
https://doi.org/10.37467/gkarevmedica.v9... The violation of such a basic right should not occur even when mothers and their offspring are incarcerated,²⁴24. Guimarães ML, Guedes TG, Lima LS, Morais SCRV, Javorski M, Linhares FMP. Promoção da aleitamento materno no sistema prisional a partir da percepção de nutrizes encarceradas. Texto & Contexto - Enfermagem. 2018;27(4):e3030017. doi: 10.1590/0104-07072018003030017.
https://doi.org/10.1590/0104-07072018003... as the best interests of the child must always be prioritized.

Breastfeeding is therefore a matter of human rights, given that it

Breastfeeding is an integral part of the essential care for newborn human beings - at least during the first few months of life - and the primary mode of nutrition up to age two according to the World Health Organization (WHO). It therefore involves a bio-cultural phenomenology²⁶26. Massó E. Conjeturas (¿y refutaciones?) sobre amamantamiento: Teta decolonial. Dilemata. 2015;7(18):185-223.⁾ which transcends the simple act of feeding and nutrition, touching the very core of human health.²³23. Massó E. Human lactation in the anthropocene: a post-pandemic emergency. Medica Review. 2021;9(2):63-77. doi: 10.37467/gkarevmedica.v9.3125.
https://doi.org/10.37467/gkarevmedica.v9...

According to international organizations and established scientific evidence, it is possible to confirm the benefits of breastfeeding at a global level.²⁷27. León-Cava N, Lutter C, Ross J, Martín L. Cuantificación de los beneficios de la lactancia materna: Reseña de la evidencia [Internet]. Washington: Programa de alimentación y nutrición (HPN), Organización Panamericana de la Salud; 2022 [citado 10 mar 2023]. Disponible en: Disponible en: http://tinyurl.com/sybk4r3j .
http://tinyurl.com/sybk4r3j... ⁾ Its numerous physical and emotional benefits for children and mothers both in the short- and long-term are not questioned. As such, rather than emphasize the benefits of breastfeeding, we can point out the risks of not doing so at a planetary scale in the Anthropocene, given that this practice represents the physiological form of human development during exterogestation. This is so to the point that it is possible to quantify these risks and advantages with the Cost of Not Breastfeeding Tool,²³23. Massó E. Human lactation in the anthropocene: a post-pandemic emergency. Medica Review. 2021;9(2):63-77. doi: 10.37467/gkarevmedica.v9.3125.
https://doi.org/10.37467/gkarevmedica.v9... ⁾ which aims to provide policymakers and advocates with a tool for estimating the potential health, human capital, and economic benefits of expanding breastfeeding promotion and support strategies. Milk production after childbirth is, in fact, a physiological process (lactogenesis begins during pregnancy), considered a part of mothers’ sex-reproductive lives, and is greatly influenced by socio-cultural and anthropological factors.²³23. Massó E. Human lactation in the anthropocene: a post-pandemic emergency. Medica Review. 2021;9(2):63-77. doi: 10.37467/gkarevmedica.v9.3125.
https://doi.org/10.37467/gkarevmedica.v9...

On the other hand, obstetric violence has been recognized by the WHO²⁸28. Organización Mundial de la Salud. Prevención y erradicación de la falta de respeto y el maltrato durante la atención del parto en centros de salud [Internet]. Ginebra: OMS; 2014 [citado 10 mar 2023]. Disponible en: Disponible en: http://tinyurl.com/2cw4m5c9 .
http://tinyurl.com/2cw4m5c9... as:

Sadler²⁹29. Sadler M. Despertando las metáforas que dormían en la ciencia. En: Quattrocchi P, Magnone N, (eds.). Violencia obstétrica en América Latina: conceptualización, experiencias, medición y estrategias. Remedios de Escalada: De la UNLa - Universidad Nacional de Lanús. p. VII-XXI. doi: 10.18294/9789874937506.
https://doi.org/10.18294/9789874937506... observes that “although it has not been widely recognized by medical associations, it is widely utilized by women’s organizations seeking to put it on the public agenda.” Additionally, there is increasing evidence that it is a real and verifiable phenomenon: the United Nations³⁰30. Naciones Unidas. España responsable por violencia obstétrica, según el Comité de derechos de las mujeres de la ONU [Internet]. 2022 [citado 10 mar 2023]. Disponible en: Disponible en: http://tinyurl.com/hw5nbewc .
http://tinyurl.com/hw5nbewc... has held Spain responsible for this type of violence against a number of mothers, which has been defined as:

Taking these considerations into account, the main objective of the research that gives rise to this article was to study the breastfeeding experience of mothers incarcerated in the Spanish prison system, with an emphasis on the potential perceptions of practices related to obstetric violence during pregnancy, childbirth, and postpartum, and associated with difficulties in breastfeeding practice.

The motivation driving this research is to contribute to the body of knowledge on this issue for its practical application to improve public policies concerning maternal and infant health among the incarcerated population. From an intersectional perspective,³²32. Igareda N. La maternidad de las mujeres presas. En: Bodelón E, Nicolás G, (eds.). Género y dominación: Críticas feministas del derecho y el poder. Barcelona: Anthropos; 2006.⁾ we argue for the need to address these issues in prison environments, as both the typical challenges of breastfeeding and the potential occurrences of obstetric violence are likely exacerbated in an environment already highly prone to various forms of discrimination.

Conceptual-epistemological framework: prisons, women, and mothers, in intersectional discrimination

Despite the existence of penitentiary law that contemplates the possibility that incarcerated women

In a similar vein, Baldwin³⁴34. Baldwin A, Sobolewska A, Capper T. Pregnant in prison: An integrative literature review. Women and Birth. 2018;33(1):41-50. doi: 10.1016/j.wombi.2018.12.004.
https://doi.org/10.1016/j.wombi.2018.12.... argues that there is a limited understanding of mothers’ needs on the part of correctional institutions and providers of motherhood services, as well as a general lack of attention to these needs.

On the other hand, recent research has reflected on the well-being of children incarcerated alongside their mothers, examining whether the inequalities of childhood experiences marked by incarceration are justifiable from a social justice perspective.³⁵35. Bülow W, Lindblom L. The social injustice of parental imprisonment. Moral Philosophy and Politics. 2020;7(2):299-320. doi: 10.1515/mopp-2019-0044.
https://doi.org/10.1515/mopp-2019-0044... Therefore, maternal and child health policies promoting qualified and safe healthcare are of vital importance, especially with regards to reproductive rights, such as support for nutrition, childcare, and above all breastfeeding.⁹9. Santos MV, Alves VH, Rodrigues DP, Tavares MR, Guerra JVV, Calandrini TSS, Marchiori GRS, Dulfe PAM. Promoção, proteção e apoio ao aleitamento materno no espaço prisional: uma scoping review. Ciência & Saúde Coletiva. 2022;27(7):2689-2702. doi: 10.1590/1413-81232022277.19432021.
https://doi.org/10.1590/1413-81232022277... ^,1010. Santos MV, Alves VH, Pereira AV, Vieira BDG, Rodrigues DP, Tavares MR, Calandrini TSS, Ferreira EA. The vital value of breastfeeding for imprisoned women. Texto & Contexto - Enfermagem. 2022;31:e20210455. doi: 10.1590/1980-265X-TCE-2021-0455en.
https://doi.org/10.1590/1980-265X-TCE-20...

If we examine the history of prisons themselves, existing literature portrays them as relatively recent punitive structures, as it wasn’t until the late 18^th century that institutions emerged to subject convicted individuals to a regime of isolation and deprivation of liberty;³⁶36. Foucault M. Vigilar y castigar. Madrid: Siglo XXI Editores; 1979. although it is worth noting that a school of historiography exists which locates the roots of imprisonment practices in late-13^th century Christian orthodoxy.³⁷37. Abejón S. Males fembres pecadores: Genealogia de la història del càstig i de les presons de dones a Barcelona. Barcelona: Descontrol; 2021.

According to data from the latest Statistical Yearbook³⁸38. Ministerio del Interior de España. Anuario Estadístico [Internet]. España: Ministerio del Interior, Secretaría General Técnica; 2021 [citado 10 mar 2023]. Disponible en: Disponible en: http://tinyurl.com/yr2khktf .
http://tinyurl.com/yr2khktf... published by Spain’s Ministry of the Interior, by the end of 2021 there were 55,097 people incarcerated in the country’s prisons. Of these, 92.9% were men and 7.1% were women. Of the approximately 80 state-run prisons, only four were women’s prisons (Wad-Ras in Barcelona, Alcalá de Guadaíra in Seville, Madrid-I in Madrid, and Brieva in Ávila). This implies that, despite the fact that Organic Law 1/1979³⁹39. España. Ley Orgánica 1/1979, de 26 de septiembre, General Penitenciaria [Internet]. 1979 [ citado 10 mar 2023]. Disponible en: Disponible en: http://tinyurl.com/r7rdtxy .
http://tinyurl.com/r7rdtxy... establishes exclusive prisons for women, in practice female prisoners must serve out their sentences in female modules within men’s prisons.

History shows that the configuration and internal dynamics of women’s correctional institutions

In this way, women are subjected to multiple punishments: personal, being distanced from their families and for abandoning their traditionally assigned roles as “caring mother/daughter/wife;” social, for having transgressed socially expected norms for women; and that which is related to the crime itself, often having to endure harsher conditions than men during their sentence. All of this is further aggravated in the case of mothers, according to a 2021 report by the Human Rights Association of Andalucía.⁴⁰40. Asociación Proderechos Humanos de Andalucía. Informe sobre la situación de las mujeres presas [Internet]. APDHA: 2021 [citado 10 mar 2023]. Disponible en: Disponible en: http://tinyurl.com/fxwv9v64 .
http://tinyurl.com/fxwv9v64...

Aguilera and Martinez⁴¹41. Martínez R, Aguilera M. Perspectiva de género en prisión. En: XX Jornadas de los Servicios de Orientación y Asistencia Jurídica Penitenciaria (SOAJP) [Internet]. Pontevedra: 2018 [citado 10 mar 2023]. Disponible en: Disponible en: http://tinyurl.com/y5ymyvw4 .
http://tinyurl.com/y5ymyvw4... ⁾ observe that 80% of imprisoned women are mothers. Prior to the reform of Spain’s General Penitentiary Organic Law in 1996, mothers were allowed to remain in prison with their children until they reached the age of six. However, after this change in the legislation, children were only allowed to remain in correctional facilities until age three. Only in a minority of these cases - and only when the child’s age and the mother’s penal situation permits it - do mothers live with their children behind bars, in so-called Mother Units. Different types of Mother Units exist: internal (pavilions within prisons), external (buildings annexed to the prisons), mixed (blocks where both parents serve their sentences), and dependent (centers for mothers under a regime of semi-liberty) (see Table 1).

METHODS

An exploratory-descriptive study with a qualitative approach was carried out in four institutions located in four different areas of Spain: External Mother Units (UME) in Alicante, Madrid, and Seville, and the Mothers’ Division within the Wad-Ras Prison in Barcelona. Fieldwork was conducted between December 2021 and April 2022.

Since 1983, the Spanish government has had a Central Prison Administration for all penitentiary institutions within its territory, with the exception of Catalonia, where the Department of Justice has jurisdiction over penitentiary matters. Similarly, Basque Country took control of administering its prisons in May 2021.

The study population was made up of 30 adult women who were serving their prison sentences in different institutions alongside their children. Initial contact was made with the administrators of each Mother Unit, who were provided with information on the study by the researcher responsible for carrying out fieldwork and were asked to voluntarily participate. A total of 30 mothers agreed to participate in the study. The same method was used to establish dates and times that fieldwork would be carried out, and authorization was obtained from the General Secretary of Penitentiary Institutions and Catalonia’s Department of Justice. As required, written informed consent was obtained from all participants who were interviewed for the study. From the early stages of this research project, the design of the work plan was supervised and approved in accordance with the legal framework of the Doctoral Program at the University of Granada, including the revision and approval of ethical aspects.

Critical ethnography was employed, which

This is consistent with the topic and type of research conducted, related to complex situations of social vulnerability and with a population (interviewees) facing intersectional discrimination.

Primary research techniques included semi-structured interviews⁴³43. Ibarra-Sáiz MS, González-Elorza A, Rodríguez-Gómez G. Aportaciones metodológicas para el uso de la entrevista semiestructurada en la investigación educativa a partir de un estudio de caso múltiple. Revista de Investigación Educativa. 2023;41(2):501-522. doi: 10.6018/rie.546401.
https://doi.org/10.6018/rie.546401... and participant observation.⁴⁴44. Taylor SJ, Bogdan R. Introducción a los métodos cualitativos de investigación: La búsqueda de significados. Barcelona: Paidós; 1987. Semi-structured interviews offer greater flexibility than structured interviews or closed questionnaires, allowing for adjustments in the predefined interview guide to be made by researchers, which was slightly modified as data collection progressed. This was to ensure the necessary adaptability in the qualitative research process, particularly in a challenging environment such as a correctional institution. Lastly, participant observation was conducted in a structured and pragmatic fashion, in order to obtain information on the day-to-day activities and interactions of mothers in their habitual environments.

All interviews were held in a private area in order to ensure confidentiality, and they had a duration of 15 to 70 minutes, with an average of 31 minutes. Interviews were held until reaching the point of saturation; they were recorded in a digital format and then transcribed verbatim. Material was analyzed according to the principles of grounded theory⁴⁵45. Glaser BG, Strauss A. The discovery of grounded theory: Strategies for qualitative research. Mill Valley: Sociology Press; 1967. utilizing MAXQDA software, and the constant comparison method was employed, which seeks to “base concepts on data […] and therefore necessitates the critical thinking and creativity of researchers.”⁴⁶46. Osses S, Sánchez I, Ibáñez FM. Investigación cualitativa en educación: hacia la generación de teoría a través del proceso analítico. Estudios Pedagógicos (Valdivia). 2006;32(1):119-133. doi: 10.4067/S0718-07052006000100007.
https://doi.org/10.4067/S0718-0705200600... The following emergent categories resulted from this process: 1) the motivation to breastfeed and the perception of breastfeeding agency; 2) difficulties and interferences perceived during breastfeeding, and/or in relation to its support and promotion in the healthcare and prison systems; 3) breastfeeding acculturation and misconceptions about breastfeeding; and 4) situations of obstetric violence.

Due to the fact that this research was conceived from a feminist and gender-based perspective, an intersectional³²32. Igareda N. La maternidad de las mujeres presas. En: Bodelón E, Nicolás G, (eds.). Género y dominación: Críticas feministas del derecho y el poder. Barcelona: Anthropos; 2006. theoretical framework was constructed, being “the most widespread feminist trope for speaking about either identity or multiple and interdependent inequalities.”⁴⁷47. Viveros M. La interseccionalidad: una aproximación situada a la dominación. Debate Feminista. 2016;53:1-17. doi: 10.1016/j.df.2016.09.005.
https://doi.org/10.1016/j.df.2016.09.005... Furthermore, this includes positions that take into account the epistemology of emotions in the research process.⁴⁸48. García D, Ruiz M. Un viaje por las emociones en procesos de investigación feminista. Empiria: Revista De metodología De Ciencias Sociales. 2021;50:21-41. doi: 10.5944/empiria.50.2021.30370.
https://doi.org/10.5944/empiria.50.2021....

RESULTS AND DISCUSSION

In this section we present and discuss the results of our research, given that both the points of contact with existing literature on this issue and intersectional and feminist perspectives connect with the results of the study in dynamic and systematic ways.

Socio-demographic data: age, origin, education/work

The study population (Table 2) was made up of 30 adult women who were serving prison sentences with their children in different correctional centers. Their ages ranged from 19 to 45 years old. Of the women in Mother Units, 53% were in the 31-40 age group, followed by the 18-30 group. In other words, the majority of women were between 18 and 40 years old, which can be generally considered reproductive age.

The mothers interviewed came from Africa, Europe, Latin America, and Eastern Europe; 53% were of Spanish origin. This may be due to the fact that in Mother Units, most women serving sentences are granted some flexibility in penitentiary classification in accordance with Article 100.2 of the Penitentiary Regulation. In some cases they are even granted third-degree classification, meaning that they serve a custodial sentence but under a regime of semi-liberty (except in the Alicante Mother Unit, which houses pre-trial detainees, long-term convicts, those convicted of serious or very serious crimes, or those exhibiting certain maladaptive behaviors or significant mental disorders). Therefore, alternative measures may have been adopted before they were able to serve their sentence in Mother Units, such as deportation in the case of foreign women, according to criteria outlined in Organic Law 10/1995, of 23 November, of the Criminal Code (Article 89).⁴⁹49. España. Ley Orgánica 10 de 1995 del Código Penal [Internet]. 1995 [citado 10 mar 2023]. Disponible en: Disponible en: http://tinyurl.com/yeyrhrxv .
http://tinyurl.com/yeyrhrxv...

Regarding educational level, the majority had less than a primary school education (18 of the women), followed by secondary school (8) and university (2). In terms of occupation, 33% of the mothers worked in the hotel sector, 20% were homemakers, and 16% were cleaning personnel. According to Yagüe,⁵⁰50. Yagüe Olmos C. Mujeres en prisión: Intervención basada en sus características, necesidades y demandas. Revista Española de Investigación Criminológica. 2007;(5):4. doi: 10.46381/reic.v5i0.29.
https://doi.org/10.46381/reic.v5i0.29... ⁾ analyses of the socioeconomic background of incarcerated women show that they come from the most disadvantaged sectors of society, with a clear history of discrimination and exclusion behind them: fractured families (on the brink of poverty), issues with drug abuse, limited or nonexistent education and professionalization, victims of gender-based violence, heavy burdens of family responsibility, among others. These circumstances, in addition to putting women at risk for engaging in criminal behavior, impede potential reinsertion after they have served their sentences, plunging them into a cycle of poverty and marginalization. In short, prison “excludes women who were not excluded prior to incarceration and exacerbates the marginalization of those who were already marginalized.”³³33. Crenshaw K. Demarginalizing the intersection of race and sex: A black feminist critique of antidiscrimination doctrine, feminist theory and antiracist politics. University of Chicago Legal Forum. 1989;1(8):139-167.

The data in Table 3 show that a total of 30 women were serving a prison sentence alongside a son or daughter, and one of them was pregnant; a few mothers had two children in prison. It is important to note that in addition to being incarcerated with one or more children, these women are also responsible for children outside of the facilities: 43% had more than two children outside of prison, followed by 20% with one or two children, and 13% with no children outside of prison. The lack of Mother Units results in a dispersion that leads to greater difficulties in maintaining contact with their children not in prison, and “inevitably, women have to endure the loss of emotional ties due to the separation from their sons and daughters.”³³33. Crenshaw K. Demarginalizing the intersection of race and sex: A black feminist critique of antidiscrimination doctrine, feminist theory and antiracist politics. University of Chicago Legal Forum. 1989;1(8):139-167.

Specific data regarding breastfeeding

Regarding breastfeeding, Table 4 shows that 77% of the women interviewed reported having breastfed their child while in prison. Of the 23 women who did, over 50% opted for exclusive breastfeeding while the remainder chose mixed feeding. Regarding the duration, nine of the women breastfed for 0 to 3 months, five did so for 4 to 6 months, none of the mothers did so for the range of 7 to 24 months, and only one did for longer than 24 months. The remainder of women who participated were still nursing at the time of the interview.

As is customary in anthropological-ethnographic studies, we will now present our findings alongside the terms, expressions, and narratives of the women themselves, presenting representative or significant excerpts from interviews verbatim, always preserving the original language and expressions.

Emergent categories

Motivation for breastfeeding and perceptions surrounding their breastfeeding agency

Consistent with what we presented in the first section of the article, the majority of mothers recognize and value breastfeeding their children, but different viewpoints are evident in their narratives, related to internal or external motivations.

Some of them expressed a desire to feel first-hand what breastfeeding was like and the experience of skin-to-skin contact:

Others considered breastfeeding to be the best form of nutrition for their children to grow in a healthy way:

They also alluded to breastfeeding as a way to establish and maintain a mother-child bond:

This last point is particularly important in a context where there is a high likelihood of separation and the fear that this can happen is always present. Therefore, breastfeeding can contribute to generating what Bronfenbrenner⁵¹51. Bronfenbrenner U. La ecología del desarrollo humano. Barcelona: Paidós Ibérica; 1987. calls a healthy ecosystem that encourages healthy attachment.⁵²52. Ainsworth MDS. Object relations, dependency, and attachment: A theoretical review of the infant-mother relationship. Child Development. 1969;40:969-1025.^,5353. Bowlby J. Attachment and loss. 2nd ed. New York: Basic Books; 1969.

Moreover, breastfeeding is often experienced as a form of empowerment, as it implies reclaiming “agency over one’s own body.”²⁶26. Massó E. Conjeturas (¿y refutaciones?) sobre amamantamiento: Teta decolonial. Dilemata. 2015;7(18):185-223. Something similar goes on within prison walls, where breastfeeding proves to have a positive effect on incarcerated women, given the systematic removal of their decision-making power in this context (“they even decide when I get to call my family”). It provides them with a chance to freely occupy a space (“I can breastfeed anywhere in the prison”), since prison is a space in which limits and prohibitions are constantly imposed upon them. This could imply a potentially protective aspect, as prison constitutes a limitation both on on the lives of prisoners as well as their bodies, with severe physical, mental, emotional, and social consequences.⁵⁴54. Valverde J. La cárcel y sus consecuencias: La intervención sobre la conducta desadaptada. Madrid: Popular; 1997.

Several mothers expressed a desire to have been able to experience this, although on some occasions they were not able to fulfill this desire:

Moreover, not being able to breastfeed their children caused intense feelings of sadness for them:

They even allude to the fact that this was a source of trauma for them:

Feelings of guilt regarding not breastfeeding their children were also evident, which can negatively impact their relationship with their children and/or their self-esteem. This is an issue that has been dealt with for some time within the critical promotion of breastfeeding.⁵⁵55. Olza I, Ruiz-Berdún D, Villarmea S. La culpa de las madres: Promover la lactancia materna sin presionar a las mujeres. Dilemata. 2017;25(21):217-225.

Furthermore, they expressed knowledge about the fact that in the act of breastfeeding a strong bond is created and that is very beneficial in terms of cultivating healthy mother-child attachment.⁵²52. Ainsworth MDS. Object relations, dependency, and attachment: A theoretical review of the infant-mother relationship. Child Development. 1969;40:969-1025.^,5353. Bowlby J. Attachment and loss. 2nd ed. New York: Basic Books; 1969.

Difficulties and interferences perceived during breastfeeding, and/or in relation to its promotion and support in the healthcare and penitentiary systems

It is well known that in the majority of cases where breastfeeding is not successfully carried out, this is not directly caused by the behavior or actions of mothers, but rather by different interferences and a lack of adequate support in their immediate surroundings. This is particularly relevant in the case of incarcerated women, who already face extreme vulnerability and are in much more disadvantageous conditions in comparison to mothers who experience this while free.

Some of the difficulties that they express/experience have to do with the possibility that they could be separated from their infant at some point in time; for example, due to detainment:

Another barrier that mothers can encounter during this time is that medical processional recommend they stop breastfeeding under the pretense of administering certain medications, similar to what happens outside of prisons.

On occasion, these recommendations are not based on up-to-date scientific evidence, and “unfamiliarity with the benefits of breastfeeding and with recent studies on pharmacokinetics in breast milk often leads to psychiatrists or primary care physicians to recommend early weaning so that a mother can begin psychopharmacological treatment.”⁵⁶56. Olza I, Serrano E, Muñoz C. Lactancia para psiquiatras: Recomendaciones sobre el empleo de psicofármacos en madres lactantes. Archivos de Psiquiatría. 2011;74(1):2.⁾

The mental health of mothers is compromised due to multiple factors which are far more common among incarcerated individuals, who are more vulnerable to them: “pregnancies are often unplanned and there are complications due to lack of prenatal care, maternal trauma, poor nutrition, substance abuse, mental disorders, chronic medical conditions, low socioeconomic status, and limited social support.”²⁰20. Friedman SH, Kaempf A, Kauffman S. The realities of pregnancy and mothering while incarcerated. The Journal of the American Academy of Psychiatry and the Law. 2020;48(3):365-375. doi: 10.29158/JAAPL.003924-20.
https://doi.org/10.29158/JAAPL.003924-20... The combination of all these factors frequently leads these mothers to require psychopharmacological treatment.

There is solid evidence that some antidepressants, anxiolytics, and even lithium carbonate can be compatible with breastfeeding when used with caution,⁵⁶56. Olza I, Serrano E, Muñoz C. Lactancia para psiquiatras: Recomendaciones sobre el empleo de psicofármacos en madres lactantes. Archivos de Psiquiatría. 2011;74(1):2. as demonstrated by the e-lactancia project led by the Association for the Promotion of and Scientific and Cultural Research into Breastfeeding (APILAM).

However, there are still healthcare professionals that advise against breastfeeding without truly well-founded arguments, violating the premise that “the benefits of breastfeeding far exceed those of artificial feeding, so healthcare professionals should be aware of these benefits and promote the continuity of breastfeeding whenever possible.”⁵⁶56. Olza I, Serrano E, Muñoz C. Lactancia para psiquiatras: Recomendaciones sobre el empleo de psicofármacos en madres lactantes. Archivos de Psiquiatría. 2011;74(1):2.

Regarding the mental health of mothers, it should be noted that one of the Mother Units has a perinatal mental health project, a program that addresses mental disorders experienced by women during pregnancy and/or in the first 12 months postpartum. However, we found that these interventions were not sufficient or timely for the target population, given that the mothers in this Unit did not identify the interventions conducted and expressed having felt a lack of psychological support during the perinatal stage.

It is likely that the extremely difficult circumstances of being deprived of their freedom, along with the hostile environment they face in prison, lead to specific interferences with exclusive breastfeeding, since this is a complex and fragile process which necessitates that the mother feel she is able to do so, as well as have the desire to do so. In many cases, learned defenselessness is evident:

On the other hand, some of the mothers report having experienced serious difficulties due to physical pain while breastfeeding their infants, due to improper latch, ineffective positioning, and so on. Evidence shows that there is an association between early problems and poor technique, with “correct breastfeeding technique forming the basis of successful breastfeeding and prevention of breastfeeding-associated breast problems such as nipple fissures, breast engorgement, or mastitis.”⁵⁷57. Fernández IM, Fernández CT. Lactancia materna: prevención de problemas tempranos en las mamas mediante una técnica de amamantamiento eficaz. Enfermería Global. 2013;31:443-451.

Regarding the perception of having received help when facing potential difficulties during their experience, the narratives suggest that in most cases there is not a strong sense of having received effective support from staff (healthcare or otherwise) in Mother Units. Despite the critical importance of this assistance in breastfeeding practice, there are not always strategies for promotion, protection, and support in prisons - or outside of prison, for that matter - which successfully reach incarcerated women in a meaningful and effective way.⁹9. Santos MV, Alves VH, Rodrigues DP, Tavares MR, Guerra JVV, Calandrini TSS, Marchiori GRS, Dulfe PAM. Promoção, proteção e apoio ao aleitamento materno no espaço prisional: uma scoping review. Ciência & Saúde Coletiva. 2022;27(7):2689-2702. doi: 10.1590/1413-81232022277.19432021.
https://doi.org/10.1590/1413-81232022277... This could largely explain the worldwide social hypogalactia that has been analyzed and described, stemming from widespread social acculturation surrounding breastfeeding:²³23. Massó E. Human lactation in the anthropocene: a post-pandemic emergency. Medica Review. 2021;9(2):63-77. doi: 10.37467/gkarevmedica.v9.3125.
https://doi.org/10.37467/gkarevmedica.v9...

It was also possible to detect a significant lack of support when mothers were hospitalized after giving birth:

Several mothers reported asking for help from healthcare professionals, both within and outside the prison, and they recommended using formula instead of breast milk:

Nevertheless, in some narratives the women mentioned on occasion encountering healthcare professionals that encouraged breastfeeding and supported them when they had difficulties, either staff at the detention center or external midwives:

In their “herstories”⁵⁸58. Morgan R. Sisterhood is powerful: An anthology of writings from the women’s liberation movement. New York: Random House; 1970. - a feminist notion derived from a play on words literally meaning “her story,” which has been employed by Massó to reconstruct life histories of breastfeeding mothers/“lactivists” - it is clear that these mothers turn to friends and acquaintances (peers) when they have questions or problems during breastfeeding, even before consulting with a medical professional. This is due to the fact that they trust in the experience of others (their peers, their equals) who are already mothers, because they feel more comfortable sharing their uncertainties with a woman similar to them. This is analogous to the logic of lactivism (pro-breastfeeding activism), which “displays a unique combination of the traditionally dualistic arenas of the public-private or nature-culture, constituting a transformative politics of bodies, customs, and societies:”²2. Massó E. Una etnografía lactivista: la dignidad lactante a través de deseos y políticas. AIBR. Revista de Antropología Iberoamericana. 2015;10(2):231-257. doi: 10.11156/aibr.v10i2.68023.
https://doi.org/10.11156/aibr.v10i2.6802...

In fact, there is explicit discourse regarding the gender of healthcare professionals and which are their most trustworthy sources of information:

All of this shows that even today there is a lack of (or not enough) healthcare personnel with up-to-date training on breastfeeding, despite numerous studies (biological and epidemiological) showing that the decision to not breastfeed has significant negative effects on the nutrition, development, and health of both the baby and the mother (as we pointed out at the beginning). This signifies that breastfeeding is the healthcare intervention that obtains the largest health benefit for the lowest economic cost;⁶⁰60. López de Aberasturi A, Santos N, Ramos Y, García M, Artola C, Arara I. Prevalencia y determinantes de la lactancia materna: estudio Zorrotzaurre. Nutrición Hospitalaria. 2021;38(1):50-59. doi: 10.20960/nh.03329.
https://doi.org/10.20960/nh.03329... ⁾ or, in other words, it is the healthcare practice with the most advantageous cost-benefit ratio.²³23. Massó E. Human lactation in the anthropocene: a post-pandemic emergency. Medica Review. 2021;9(2):63-77. doi: 10.37467/gkarevmedica.v9.3125.
https://doi.org/10.37467/gkarevmedica.v9...

Breastfeeding acculturation and misconceptions about breastfeeding

Several of the narratives shed light on the reproduction or adoption of certain misconceptions regarding breastfeeding that have spread throughout Western culture, particularly since the second half of the 20^th century, based on the influence of so-called “bottle-feeding culture.” In other words, this could be thought of as a genuine breastfeeding acculturation,⁶¹61. Massó E. Lactancia materna y revolución, o la teta como insumisión biocultural: calostro, cuerpo y cuidado. Dilemata. 2013;11:169-206. which has led to a worldwide pandemic of social hypogalactia,²³23. Massó E. Human lactation in the anthropocene: a post-pandemic emergency. Medica Review. 2021;9(2):63-77. doi: 10.37467/gkarevmedica.v9.3125.
https://doi.org/10.37467/gkarevmedica.v9... consistent with troublingly low rates of breastfeeding.⁶²62. Martín-Ramos S, Domínguez-Aurrecoechea B, García Vera C, Lorente García Mauriño AM, Sánchez Almeida E, Solís-Sánchez G. Lactancia materna en España y factores relacionados con su instauración y mantenimiento: estudio LAyDI (PAPenRed). Atención Primaria. 2024;56(1):102772. doi: 10.1016/j.aprim.2023.102772.
https://doi.org/10.1016/j.aprim.2023.102...

We speak of misconceptions⁶³63. López EP. Estudio bibliométrico sobre mitos y verdades de la lactancia materna. Npunto. 2022;5(50):136-154. that have been socially and culturally transmitted (an erroneous and harmful breastfeeding socialization), along with highly ingrained opinions, as factors that contribute to the loss of breastfeeding culture and appropriate socialization into this biocultural practice. Moreover, these misconceptions have been revised and countered for some time from the perspective of feminist phenomenology.²2. Massó E. Una etnografía lactivista: la dignidad lactante a través de deseos y políticas. AIBR. Revista de Antropología Iberoamericana. 2015;10(2):231-257. doi: 10.11156/aibr.v10i2.68023.
https://doi.org/10.11156/aibr.v10i2.6802... ⁾ They often come from healthcare professionals themselves (both inside and outside prison), from prison staff (educators, officials, etc.), and indeed from other inmates. This may lead to interference with initiating and continuing breastfeeding, with severe consequences for the women’s experiences. For example, frequent reference is made to a “lack of milk” or “poor milk production:”

We also encountered references to “incorrect” breast size or shape (even though there is scientific evidence⁶⁴64. Calama Valero JM. Mitos sobre la lactancia materna. En: Aguayo Maldonado J, (ed.). Manual de lactancia materna. Madrid: Editorial Médica Panamericana; 2009. p. 403-410. that there is no physiological basis for this; all breasts are capable of milk production, except for a small percentage linked to certain conditions, with no statistical significance):

Allusions to the supposed “poor quality” of breastmilk and to “bad breasts” could also be observed:

We also registered references to prolonged breastfeeding,⁶⁵65. Ausona M. “Encara li dones el pit?” Tabús occidentals envers els usos de la corporalitat en la criança. Quaderns-E. 2013;18(1):114-127. that is, the belief that past a certain age breastfeeding should be discontinued and is frowned upon:

Regarding the ingrained belief that breastfeeding is painful and that it is “normal” to feel pain, some of the mothers declared:

Situations related to obstetric violence

From several of the mothers’ narratives that were analyzed it was also possible to detect situations of obstetric violence exerted against them and/or their infants. As previously mentioned, this issue is structurally linked to the practice of breastfeeding and it has a direct and negative impact on its effective initiation.

Mothers reported having been subjected to obstetric violence throughout the entire perinatal period by healthcare personnel (both in prison facilities and in hospital settings), whether by action or omission, which led to serious consequences for their health:

The narratives also describe situations of mistreatment during the postpartum period, a particularly vulnerable stage for mothers who have just given birth. This is despite the growing body of scientific evidence showing that “the emotional state of the woman during pregnancy, childbirth, and postpartum has significant repercussions, both for her and for the baby she carries, for the physical and mental health of each and every member of the family, in the short and long term:”⁶⁶66. Olza I, Fernández P, González A, Herrero F, Carmona S, Gil A, Amado E, Dip ME. Propuesta de un modelo ecosistémico para la atención integral a la salud mental perinatal. Revista de la Asociación Española de Neuropsiquiatría. 2021;41(139):33-35.

It is known that postpartum depression can manifest in 10% to 15% of women. Risk factors for postpartum depression, according to Antúnez et al., include:

Other risk factors for postpartum depression include: birth by cesarean section, primiparity, and preexisting mental health disorders.⁶⁷67. Antúnez M, Martín N, Casilari JC, Mérida FJ. Depresión posparto, análisis de los factores de riesgo y la intervención de Enfermería: Revisión bibliográfica. Enfermería Cuidándote. 2022;5(3):19-29. doi: 10.51326/ec.5.3.2558670.
https://doi.org/10.51326/ec.5.3.2558670... ⁾ Studies have shown that women who face postpartum depression experienced stress factors in their lives during pregnancy and after childbirth.⁶⁷67. Antúnez M, Martín N, Casilari JC, Mérida FJ. Depresión posparto, análisis de los factores de riesgo y la intervención de Enfermería: Revisión bibliográfica. Enfermería Cuidándote. 2022;5(3):19-29. doi: 10.51326/ec.5.3.2558670.
https://doi.org/10.51326/ec.5.3.2558670... ^,6868. O’Hara MW. Social support, life events, and depression during pregnancy and the puerperium. Archive of General Psychiatry. 1986;43(6):569-573. doi: 10.1001/archpsyc.1986.01800060063008.
https://doi.org/10.1001/archpsyc.1986.01... ⁾ Some of these circumstances were present in the narratives of incarcerated women, and many of them reported having experienced high stress levels. Similarly, several of the women reported having felt extreme sadness, and suspected or had a feeling that they could be experiencing postpartum depression, despite never having been diagnosed by a healthcare professional.

They also reported being subjected to humiliating and degrading treatment, infringing on the most basic rights of mothers and infants, both through direct actions and through a failure to promote, encourage, and support breastfeeding, representing a specific form of bodily discrimination:

CONCLUSIONS

The primary objective of this article, as mentioned above, was to analyze the breastfeeding experiences of incarcerated women in the Spanish penitentiary system in order to potentially detect perceptions of practices related to obstetric violence during the perinatal period. Furthermore, we sought to delve into the experience of breastfeeding during pregnancy, childbirth, and postpartum for both women and their infants incarcerated in different Mother Units across Spain, in order to document and more clearly understand a critical and problematic situation, and wherever possible formulate appropriate and informed recommendations.

Based on these objectives and the analysis of our main results, we find a need for public and penitentiary policies that align with WHO recommendations (infants should be exclusively breastfed for the first six months of life, followed by the introduction of nutritionally adequate and safe complementary foods, together with breastfeeding up to at least two years of age). Moreover, such policies should outline strategies to ensure breastfeeding, and also to put an end to the serious violations of human rights to which women are exposed - the right to food and physical, psychological, and emotional health, as well as sexual and reproductive rights, since lactation is an essential part of the sexual cycle in women who are mothers.

Therefore, specific policies should also be formulated and implemented to prevent violent practices (by action or omission) both in a physical sense (uninformed, inappropriate, non-consensual, non-consented acts) and a psychological sense (paternalistic, authoritarian, humiliating, degrading treatment), that are commensurate with obstetric violence and therefore constitute a violation of human rights.

It is necessary to provide up-to-date training and professional development on these issues for all parties involved during incarceration, so that they can ensure the well-being of mothers and infants during the perinatal period and have the tools to effectively and meaningfully implement actions to promote, protect, and support breastfeeding.

Similarly, there is an urgent need for perinatal mental health professionals in correctional facilities, who can respond to the specific needs of women who are serving sentences during this period. Although our research has identified difficulties for incarcerated mothers - in many ways analogous to those experienced by others - the crucial element revealed (emphasizing an intersectional perspective) is that incarceration adds to a complex web of discrimination, deepening and accentuating inequalities.

Although they are still partial and open-ended, the findings of this study make a valuable contribution to the body of knowledge on motherhood in prisons, on the (complex and delicate) perinatal period for mothers/infants in this situation, and ultimately on breastfeeding itself, a fundamental phenomenon for human health and a fundamental right both of all children and all women who become mothers. Therefore, it is necessary to continue advancing knowledge in this field to further explore this population and delve into the various issues related to our research objective that require further examination. For example, there should be a deeper exploration of experiences related to obstetric violence in general in correctional settings, and in particular the approach to perinatal mental health.

For these reasons, the main conclusion of this article has to do with the undeniable need to apply penitentiary policies with a gender-based, feminist perspective that protect the most basic rights of mothers and infants - in addition to attempting to eradicate the serious inequalities and discriminations suffered by incarcerated women - while offering an effective response to their situation in accordance with human rights, especially regarding their breastfeeding practice, which is also a basic human right.

ACKNOWLEDGEMENTS

We are deeply grateful to the incarcerated mothers who participated in this study, their contribution was essential to obtain the results presented in this article.

References

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