The findings of the present study show that the majority of the incarcerated women in the country are young mothers of reproductive age. These results imply the urgent need for prisons to adapt to the specific demands of these women and to offer them a full range of reproductive health services, be they preventive or curative. Many of these women are in the economically active period of their lives. Most worked before being incarcerated and just over 1/3 were the main source of the family income. This income is lost to the families, adding to the cycle of poverty. These women started in deficit to begin with, given the substantial gender-related disparities in income in Brazil [14, 15]. The scenario of the feminization of poverty is evidenced in this study where many women were responsible for Family income before incarceration.
Approximately half of the women studied reported having given birth to, children or adolescents under age 19, and 40% of these were under 10 years old at the time of the study. In 2016, a law was passed in Brazil aimed at guaranteeing pregnant women and mothers of children under the age of 12 the opportunity to serve their sentence at home, attempting to ensure greater support for the child. To realize this benefit, the woman must not have committed a crime against her children, not be part of a criminal gang, and not be a repeat offender [16]. The law would guarantee maternal presence in the family and would contribute to women being able to work, since around 37.3% of Brazilian women in general, and 87.4% of single mothers with children are heads of household [17]. Nevertheless, due to recidivism or being convicted of drug traffiking, many women do not meet these criteria, and for those that do, having no evidence of fixed permanent address, or being unable to present documentation, such as birth records or demonstration of children living with them or being accused of risky conduct that threatens the child from a spouse, ex-spouse, or other family member excludes them from the benefit [18, 19]. For these women, being pregnant or having young children means that their children will be in the care of family members, neighbors, or in state custody [20], increasing the rate of institutionalized children [21]. For the children of imprisoned mothers, the absence of their mother can be profound in both developmental terms and in relation to peers, neighbors and the community [21, 22]. The narrative of maternal status, relations to ones’mother and personhood in Brazil has broad repercussions. The distancing created by incarceration affects the health status of the mother and can have disastrous consequences for children, during childhood, adolescence and adulthood [22, 23]. Knowing the effects on their children’s lives generates mixed feelings in women. After all, many want their children nearby and wish to be there during critical moments. On the other hand, they do not want them exposed to the environment of Brazilian prisons, which are certainly unsuitable for children, even without the strict body cavity search that takes place prior to family visits [6].
This study showed something of the reality of Brazilian women in prison. The large number of women of color and women of low income in prison marks social and class differences, and makes the judicial system suspect. The large number incarcerated for drug crimes speaks more to society’s addictions and the predatory behavior of partners than individual moral qualities. Incarceration is associated with family disintegration, poor social conditions, low education, little expectation of social reintegration, and the difficulty of improving their lives [24]. Given these circumstances, women find themselves without expectations of change in their social and financial conditions after prison, favoring recidivism. Approximately 68.1% of the women are repeat offenders, with drug trafficking as the main reason for prison. The motivations for drug trafficking can be difficult to parse. Women’s involvement in trafficking includes not realizing that it is a “crime”, but rather slightly illegal work needed to support the family encouraged by a partner. Sometimes women are motivated by disappointment in relationships, or are users and need to support their habit [25, 26]. Motivations can reach the level of novelistic pathos, with prison reported in one trial account an attractive option for a HIV+ women from a country that does not provide ARVs, since treatment is purportedly guaranteed in Brazilian prisons [27, 28].
The abandonment of family members and partner/spouse while in prison may also be a factor in health in prisons. It induces loneliness and may contribute to the emergence of psychological disorders and dependence on alcohol and illicit drugs, as well as hindering social reinsertion [11]. Around 32% of women prisoners do not receive visits in prison. This percentage is much higher for intimate visits, 90% do not receive an intimate visit, although intimate visits are legally guaranteed for men and women [29]. However, such rights are hindered and/or neglected for women. Approximately 52% of female prisoners have partners who are also imprisoned, a fact that renders intimate visits even more difficult [30]. In order for the female inmate to go to another prison unit, for the intimate visit to her partner, some conditions such as police escort and prior scheduling are required [28], making us question whether, in view of such bureaucracies and the current prison situation in Brazil, this right is really guaranteed. Travel when possible, is generally carried out by women, with men not traveling to meet with their partners. Intimate visits should be held in a suite where the couple can stay for up to 2 h, bimonthly. However, most prisons do not have this space. Finally the benefit is granted only to those who can prove consensual union or who are married [28].
Female prisoners are abandoned in every way. Partner abandonment can also contribute to poor adherence to contraceptive methods (28.5%), with oral contraceptives (44.7%), injectable contraceptives (37.1%) and condoms (30%) being the most frequently utilized methods. In the prison system, only 15% of the women reported receiving condoms for free. As for condom use, 69.9% of the women denied using them. This figure may be less alarming taking into consideration the difficulty of negotiating with their partners, restricted access, and high reported levels of same sex relationships [31, 32].
When women use a contraceptive method, they are seeking to prevent another unwanted pregnancy or reduce the risk of abortion, with oral and injectable contraception being the most widely used and accessible resource within and outside the prison system [33, 34]. In Brazil, the frequency of abortion is elevated, although condemnation of abortion is almost universal. Addressing abortion is made difficult because voluntary abortion is illegal, and the topic is treated from a religious and moral perspective. For the majority of women, however, voluntary abortions are performed in a two-stage fashion. First, women initiate abortion outside of hospital, and then, once initiated, or following abortion, attend the hospital for completion. This procedure leads to a high rate of complications [35]. In prisons, women who have abortions tend to be isolated and expelled from their cells and are sent to a specific “safe” place, which, in male prisons, is destined for rapists and/or “child killers” [20].
Prisoners are poor women coming from marginal and precarious living environments who may not have had access to quality health care. This renders it a suitable locus for the implementation of preventive strategies, as well as the provision of basic health services, including early detection of breast cancer and cervical cancer prevention [24]. For many women, incarceration is the only opportunity to gain access to health services [33]. For the year 2018, it is estimated that 59,700 new cases of breast cancer and 16,360 new cases of cervical cancer occur in the female population of Brazil. Gynecological examination and cervical cancer screening are an effective strategy for the early detection of many diseases [35]. The last cervical cancer screening for 76.8% of the women in our sample took place 3years previously. While the recommendation for cervical cancer screening is every 3 years if the last two annual exams were normal [36] there is reason to believe that women in prison represent a higher risk population. In several studies, women aged 40 and older in prison demonstrated a risk of developing cervical cancer 4 to 5 times higher compared to the general population [37, 38]. Such vulnerability intensifies when early sexual debut occurred, the individuals are smokers, and they have prolonged use of oral contraceptives [39].
Regarding mammograms in prison, 42,7% of women over the age 50 have never done reported the exam. These results are similar to the study conducted by Audi (2016), [24], who identified low prevalence of both cervical cancer screening and mammograms. Several factors are associated with low number of mammograms, including being single, having little education, being of low social class, lack of knowledge of prevention methods, and lack of access to free services [40]. Due to the high percentages of young women in prison, there are great consequences in not carrying out the appropriate breast cancer screening program [24]; screening has been demonstrated to be an essential strategy for reducing breast cancer mortality in women aged 40 to 49 years old [41].
In addition to screening for breast and cervical cancers, STI symptoms need to be investigated during consultations. The occurrence of other STIs, associated with the profile of women and men in prison and low levels of condom use, potentiate the risk for HIV/AIDS, contributing to a serious public health problem within and outside the prison system, including high risk behavior post-release [42,43,44]. Asymptomatic STIs, such as chlamydial infections (75%), gonorrhea (50%), and many cases of HIV and syphilis occur are transmitted and may lead to complications such as sterility [45]. Prison health systems can do much to reduce health inequity by treating this population [46,47,48].
