Abstract

Introduction

This article aims to reflect on homeless women’s motherhood. An integrative review ¹1. Vosgerau D, Romanowski J. Estudos de revisão: implicações conceituais e metodológicas. Revista Diálogo Educacional 2014; 14:165-89. was used to examine scientific discourses, analyzing how they present themselves and intersect with biomedical, legal, and social propositions on this subject.

The idea of woman and its association with motherhood is a social construction ²2. Butler J. Problemas de gênero: feminismo e subversão da identidade. Rio de Janeiro: Civilização Brasileira; 2013.. In the West, the mother figure evokes sacredness and purity, the one who cares for her children and the home. Meanwhile, homeless women have been associated with prostitution, danger, and crime ³3. Lima MS. A quem pertence essa gravidez? Reflexões sobre a maternidade/maternagem de mulheres que fazem uso de drogas e as agentes do estado [Dissertação de Mestrado]. Rio de Janeiro: Universidade do Estado do Rio de Janeiro; 2018.. To approach the experiences of motherhood for these women strains these constructs and calls for discussion on the limits between individual freedom and State intervention.

The topic has gained visibility in the international scenario since the 1950s due to the growing number of court cases and the debate on homeless women´s sexual and reproductive rights, as well as the legitimacy of “fetal rights” ⁴4. Boyd S. Mulheres, drogas e o rapto de seus filhos. In: Mendes N, Merhy E, Silveira P, organizadores. Extermínio dos excluídos. Porto Alegre: Rede Unida; 2019. p. 214-25.. The agenda has not been resolved to date, expressed in the daily reality of health, legal, and social assistance services based on dilemmas involving the defense alternating between the rights of the homeless woman and those of her fetus/infant/children.

In Brazil, the discussion on homeless women’s life and health and those of their infants has been present in the social, political, and legal debate, especially since 2012, heavily associated with drug use. The subject reached the mass media, suggesting a direct relationship between drug use and homelessness, (re)produced by the moral discourse on “addiction” in which drugs are purportedly the cause of living on the streets ⁵5. Mulheres viciadas em crack usam droga durante gestação e colocam bebês em risco. Fantástico; 2012. Vídeo: 15:19 min. https://globoplay.globo.com/v/2213203/.
https://globoplay.globo.com/v/2213203/... .

However, this discourse is not exempt from vested interests and has often proven equivocal: not everyone living on the streets uses drugs, and the reasons for homelessness vary widely, ranging from generations that that are already born on the streets to those for whom life’s circumstances make living on the streets a reality/alternative.

In addition, the sensationalist news ⁵5. Mulheres viciadas em crack usam droga durante gestação e colocam bebês em risco. Fantástico; 2012. Vídeo: 15:19 min. https://globoplay.globo.com/v/2213203/.
https://globoplay.globo.com/v/2213203/... that backs the moral discourse’s production ⁶6. Lancetti A. Contrafissura e plasticidade psíquica. São Paulo: Editora Hucitec; 2015. erase the women’s context of social vulnerability and become a relevant strategy for maintenance of the status quo and criminalization of these women, considered unfit for exercising motherhood. Such narratives thus take the “war on the poor” for granted, officially disguised as the “war on drugs”, serving to induce and justify prohibitionist strategies to the detriment of harm reduction proposals ⁶6. Lancetti A. Contrafissura e plasticidade psíquica. São Paulo: Editora Hucitec; 2015.^,77. Silveira P, Alexander BK. A "guerra às drogas" terá fim? Por quê? In: Mendes N, Merhy E, Silveira P , organizadores. Extermínio dos excluídos. Porto Alegre: Rede Unida; 2019. p. 160-85.^,88. Rodrigues T. Tráfico, guerra, proibição. In: Labate BC, Goulart S, Fiore M, MacRae E, Carneiro H, organizadores. Drogas e cultura: novas perspectivas. Salvador: EdUFBA; 2008. p. 91-104..

According to Santos et al. ⁹9. Santos GC, Constantino P, Schenker M, Rodrigues LB. O consumo de crack por mulheres: uma análise sobre os sentidos construídos por profissionais de consultórios na rua da cidade do Rio de Janeiro, Brasil. Ciênc Saúde Colet 2020; 25:3795-808., the situation of these women and their infants denounces a social ill resulting from historically unequal gender, class, and race relations that impact specific bodies: women, the vast majority of whom are black and poor, whose life history is marked by structural and institutional violence. These women live in a profound context of abandonment and neglect, challenging the established norms on the meaning of womanhood and motherhood, triggering responses by the State ³3. Lima MS. A quem pertence essa gravidez? Reflexões sobre a maternidade/maternagem de mulheres que fazem uso de drogas e as agentes do estado [Dissertação de Mestrado]. Rio de Janeiro: Universidade do Estado do Rio de Janeiro; 2018..

In recent decades, such responses have involved the structuring of a network of integrated care between primary care and mental health, with the expansion of Centers for Psychosocial Care and the deployment of Street Outreach Clinics. Meanwhile, measures have been taken to deal with the drug use, especially crack use ¹⁰10. Brasil. Decreto nº 7.179, de 20 de maio de 2010. Institui o Plano Integrado de Enfrentamento ao Crack e outras Drogas, cria o seu Comitê Gestor, e dá outras providências. Diário Oficial da União 2010; 21 mai., reinforcing a hygienist view of the homeless population, shaping a scenario of dispute over models of care, in which public funds from services in the Brazilian Unified National Health System (SUS) have been allocated to the private sector, especially to finance “Therapeutic Communities” ¹¹11. Santos MPG. Comunidades terapêuticas: temas para reflexão. Rio de Janeiro: Instituto de Pesquisa Econômica Aplicada; 2018..

Such prohibitionist measures have directly impacted homeless women’s reproductive rights. In 2014, the Office of the Public Prosecutor for Children and Youth in Belo Horizonte, Minas Gerais State, issued two Rulings ¹²12. Ministério Público do Estado de Minas Gerais. Recomendação nº 05/2014. https://dequemeestebebe.files.wordpress.com/2017/04/recomendaccca7acc83o-5_2014mp.pdf (acessado em 31/Ago/2020).
https://dequemeestebebe.files.wordpress.... ^,1313. Ministério Público do Estado de Minas Gerais. Recomendação nº 06/2014. https://dequemeestebebe.files.wordpress.com/2017/04/recomendaccca7acc83o-6_2014mp-1.pdf (acessado em 31/Ago/2020).
https://dequemeestebebe.files.wordpress.... to maternity hospitals and primary care units, recommending immediate notification to authorities of births to women drug users and/or homeless women. Two years later a new Ruling was issued ¹⁴14. Vara da Infância e da Juventude de Belo Horizonte. Portaria nº 3/VCIJBH/2016. Dispõe sobre o procedimento para encaminhamento de crianças recém-nascidas e dos genitores ao Juízo da Infância e da Juventude, assim como oitiva destes, nos casos de grave suspeita de situação de risco, e sobre o procedimento para aplicação de medidas de proteção. Diário de Justiça do Estado de Minas Gerais 2016; 22 jul., this time by the Minors’ Court in that state capital, setting a 48-hour deadline (starting at the infant’s date and time of birth) to notify the authorities, subjecting healthcare workers to penalties in case of noncompliance with the provisions.

Recent practices of separating mothers and infants, as in Belo Horizonte since 2011 ¹⁵15. Em BH, mães com histórico de uso de drogas têm seus bebês retirados na maternidade. Jornal GGN 2017; 20 jul. https://jornalggn.com.br/direitos-humanos/em-bh-maes-com-historico-de-uso-de-drogas-tem-seus-bebes-retirados-na-maternidade/.
https://jornalggn.com.br/direitos-humano... or Rio de Janeiro since 2013 (when 39 newborns were taken from their mothers because they were homeless women that used crack ³3. Lima MS. A quem pertence essa gravidez? Reflexões sobre a maternidade/maternagem de mulheres que fazem uso de drogas e as agentes do estado [Dissertação de Mestrado]. Rio de Janeiro: Universidade do Estado do Rio de Janeiro; 2018.) harken back to the 1920s to 1980s, when thousands of children of parents diagnosed with leprosy were separated and sent to so-called “preventoria”, while the parents were isolated in “leprosaria” ¹⁶16. Maricato G, Sousa ACM. Sequestro e negligência como política de Estado: experiências da segunda geração de atingidos pela hanseníase. Saúde Redes 2018; 4 Suppl 1:153-68..

Prohibitionist practices, including hospitalization, tubal ligation, and compulsory separation of women and their infants, initially limited to some Brazilian state capitals, have become the object of denunciations by human rights groups in women’s movements and universities. According to these exposés, homeless women and/or those with a history of drug use had their newborn infants kidnapped while they were still in the maternity hospitals and put up for adoption by the courts behind the mothers’ backs, even when the mothers had voiced their desire to keep their children and had pursued the means to raise them.

The exposés clearly showed that the system’s modus operandi was biased, since it focused on drug use while overlooking the women’s life history and context; selective, since the great majority of the rulings targeted poor homeless black women who were “captured” when they appeared at public healthcare or social services; and moralistic, since the same rulings rarely addressed the men who had fathered the babies ¹⁷17. Associação Brasileira da Rede Unida. Saúde Redes 2018; 4 Suppl 1:5-252..

In 2016, a Technical Note ¹⁸18. Ministério da Saúde; Ministério do Desenvolvimento Social e Combate à Fome. Nota Técnica Conjunta nº 001/2016. http://www.mpgo.mp.br/portal/arquivos/2016/10/31/18_21_17_558_Nota_T%C3%A9cnica_Conjunta_MDS_e_MS_FINAL_1.pdf (acessado em 28/Abr/2021).
http://www.mpgo.mp.br/portal/arquivos/20... by the Brazilian Ministry of Health and the Brazilian Ministry of Social Development and Fight on Hunger reiterated that parents’ vulnerability and drug use are not grounds for family separation, filing a reply to the Public Prosecutor’s Office in Belo Horizonte ⁹9. Santos GC, Constantino P, Schenker M, Rodrigues LB. O consumo de crack por mulheres: uma análise sobre os sentidos construídos por profissionais de consultórios na rua da cidade do Rio de Janeiro, Brasil. Ciênc Saúde Colet 2020; 25:3795-808.. In 2018, the journal Saúde em Redes published a special thematic edition of articles by researchers, social movements, and public defenders, joining the efforts at denouncing the abuses, signaling that in the “state of civilization that neoliberalism has produced..., some lives are worth more than others, and many lives ...that are not deemed worthy ...are left to die, or are even killed” ¹⁹19. Ferla AA, Jorge A, Merhy E. Separação compulsória de mães e seus filhos: quando a lei e a cidadania se confrontam. Saúde Redes 2018; 4 Suppl 1:5-8. (p. 7).

That same year, the United Network [Rede Unida] held the 13th International Congress (http://www.redeunida.org.br/pt-br/evento/5/), displaying hundreds of pairs of baby’ socks on a clothesline, each pair representing a newborn infant taken by force from its mother. The clothesline displayed quotes by the mothers concerning their wish to raise their children, followed by the question: “Whose baby is this?”.

The campaign denounced the State intervention’s eugenicist nature. By purportedly defending the rights of the most vulnerable, the Minors’ Court was perpetuating a structure of oppression, since it made no practical efforts to find effective solutions to the mothers’ problem as poor black homeless and/or substance-using women, or that of their infants.

All these issues motivated the current study, recognizing that the institutional responses to the health and living conditions of these women and their infants require the production of knowledge on the topic. To examine the research output on this subject means to spark a debate on health practices and policies.

Methodology

This is an integrative review study of the scientific literature on homeless women’s motherhood. Integrative reviews encompass a set of techniques to retrieve, map, select, evaluate, and produce critical analyses of knowledge production on a research object or question ¹1. Vosgerau D, Romanowski J. Estudos de revisão: implicações conceituais e metodológicas. Revista Diálogo Educacional 2014; 14:165-89..

In building an overview of a theme, an integrative review does not form a homogeneous whole, as suggested by the term “integrative”, but sometimes reveals (as is appropriate) the contradictions and deletions, allowing to identify reasons by which a research topic or agenda stands out.

The method’s choice is based on the recognition of the analytical potentialities in the way studies portray homeless women’s motherhood/parenting. There are two key questions: (i) Which propositions back the production of these studies?; and (ii) How do biomedical, legal, and sociological/anthropological knowledges permeate the social and political production of these motherhoods?

The literature survey was done in June 2019 with two search strategies using descriptors in Portuguese and English in the databases Virtual Health Library (VHL), Scopus, Web of Science, and SciELO. The first strategy consisted of the simple combination of the descriptors “women, motherhood, and street”, aimed at broader coverage (Figure 1). The second consisted of a more specific strategy incorporating more descriptors and two other domestic databases: Brazilian Open-Access Portal of Scientific Publications (Oasis) and CAPES Catalogue of Theses and Dissertations.

The retrieved studies were organized using the Mendeley software (https://www.mendeley.com), facilitating database cleaning and checking duplicates. We considered available and accessible publications in Portuguese, English, or Spanish. A first scan of the studies was done with the title, validated by two ad hoc reviewers. Next, we excluded the articles that lacked full texts. Based on reading the abstracts, we maintained the studies related in some way to the theme of homeless women’s motherhood while excluding clinical trials, routine prenatal service protocols, and specific studies on the evaluation of services that lacked discussion on homeless women.

The selected studies led to a data matrix organized with the following information: title; authors; affiliation; objective; type of study; methods/methodology; participants; principal findings; area of knowledge; language; year; place of publication; and funding support. Next, an exhaustive reading of the studies was performed, seeking to identify core meanings ²⁰20. Spink MJ. Práticas discursivas e produção de sentidos no cotidiano: aproximações teóricas e metodológicas. São Paulo: Cortez Editora; 2004.. From the perspective of discursive practices, core meanings refer to understanding language (written, spoken, imagistic, body) as social practices in action ²⁰20. Spink MJ. Práticas discursivas e produção de sentidos no cotidiano: aproximações teóricas e metodológicas. São Paulo: Cortez Editora; 2004. that express conditions of historical and political possibilities in which the production of discourses is anchored.

The analysis was performed by acknowledging biomedical, legal, and sociological/anthropological forms of knowledge as discourses and places of speech that offer different ways of viewing the topic, in permanent tension, including within each of them, given that they do not produce unique propositions. When observing these forms of knowledge and discourses, we ask, how do they connect? How are they transformed? Which disputes are in play? Which interfaces are produced between the propositions?

Results and discussions

The idea of woman is a social construction that acquired clear contours in modernity when it was associated with the ideology of instinctive love for the offspring and virtuous devotion to the home ²¹21. Badinter E. Um amor conquistado: o mito do amor materno. Rio de Janeiro: Nova Fronteira; 1985.. Women’s bodies are operated by rules and standards of normality, with science playing an important role in the construction of practices and knowledge impacting these bodies. “Woman” viewed as a synonym for “mother” reflects this constructed ideal, and whenever something questions this standard, there are tensions. Homeless women’s experiences of motherhood place the establishment in check, sparking debates and analyses in both the social and academic milieus.

The research production identified in this integrative review (Box 1) expresses different rationalities and ways of understanding these women’s experiences of motherhood. The corpus for analysis consisted of 21 studies, based on which four propositions were identified:

The organization of these articles based on the identification of these propositions considered the centrality of discussions in the studies. The organization is didactic, since the articles’ discussions overlap. The discussion on drugs also gains importance in both Brazilian and international studies. Beyond combining such diverse articles and contexts, the “drug issue” appears in the propositions as a device to justify strategies of surveillance and intervention in the bodies of these women and their children.

Health risks for the woman and the fetus/child

In 8 of the 21 studies, we identified the proposition of health risks for the woman and the fetus/child. Three studies problematized the theme based on Brazilian experiences ²²22. Kassada DS, Marcon SS, Pagliarini MA, Rossi M. Prevalência do uso de drogas de abuso por gestantes. Acta Paul Enferm 2013; 26:467-71.^,2323. Sakamoto LC, Malavasi A, Karasinb AL, Frajzinger RC, Araújo MR, Gebrim LH. Prevenção de gestações não planejadas com implante subdérmico em mulheres da Cracolândia, São Paulo. Reprod Clim 2015; 30:102-7.^,2424. Rocha PC, Alves MTSSB, Chagas DC, Silva AAM, Batista RFL, Silva RA. Prevalência e fatores associados ao uso de drogas ilícitas em gestantes da coorte BRISA. Cad Saúde Pública 2016; 32:e00192714. and five based on the international context ²⁵25. Gustavsson NS. Drug exposed infants and their mothers: facts, myths, and needs. Soc Work Health Care 1992; 16:87-100.^,2626. Bassuk EL, Weinreb L. Homeless pregnant women: two generations at risk. Am J Orthopsychiatry 1993; 63:348-57.^,2727. Bloom KC, Bednarzyk MS, Devitt D, Renault RA, Teaman V, Loock MV. Barriers to prenatal care for homeless pregnant women. J Obstet Gynecol Neonatal Nurs 2004; 33:428-35.^,2828. Schempf AH, Strobino DM. Illicit drug use and adverse birth outcomes: is it drugs or context? J Urban Health 2008; 85:858-73.^,2929. Leppo A. "Subutex is safe": perceptions of risk in using illicit drugs durin pregnancy. Int J Drug Policy 2012; 23:365-73.. Scattered across time and context, these studies share the idea that risks permeate the production of these motherhoods, due to homelessness and/or drug use.

From the conceptual point of view, risk is a probabilistic measure referring to the odds of a given problem or event occurring. In public health, the concept inaugurated a new reasoning in the way of organizing health practices and services in which preventing and controlling risk factors assumes a central position in the actions ³⁰30. Castiel LD, Guilam MCR, Ferreira MS. Correndo o risco: uma introdução aos riscos em saúde. Rio de Janeiro: Editora Fiocruz; 2015..

In the studies in this review, the propositions pertaining to risk factors for the woman and for the fetus/child appear in permanent tension: are homelessness and drug use the preponderant factors for the adverse maternal and child health outcomes, or the political and social context, often prior to life on the streets and drug use ²⁶26. Bassuk EL, Weinreb L. Homeless pregnant women: two generations at risk. Am J Orthopsychiatry 1993; 63:348-57.^,2828. Schempf AH, Strobino DM. Illicit drug use and adverse birth outcomes: is it drugs or context? J Urban Health 2008; 85:858-73.? What weight more for the adverse pregnancy outcomes in these women: substance use practices, type of substances, lifestyle, or the context of poverty, in which living on the street becomes the expression of precariousness ²⁶26. Bassuk EL, Weinreb L. Homeless pregnant women: two generations at risk. Am J Orthopsychiatry 1993; 63:348-57.^,2929. Leppo A. "Subutex is safe": perceptions of risk in using illicit drugs durin pregnancy. Int J Drug Policy 2012; 23:365-73.?

These tensions are anchored in different understandings of the risks, ranging from biomedical understanding, based on the assumption that merely living on the streets is already a risk to the pregnancy, and that adds to the drug use, to sociocultural studies contending that the risk factors are structural and thus related to the context of life’s precariousness ²⁵25. Gustavsson NS. Drug exposed infants and their mothers: facts, myths, and needs. Soc Work Health Care 1992; 16:87-100.^,2626. Bassuk EL, Weinreb L. Homeless pregnant women: two generations at risk. Am J Orthopsychiatry 1993; 63:348-57..

From the biomedical point of view, the studies emphasize the cause-consequence relationship and point to “risk-free” motherhood as the solution: the return home and abstinence from drug use ²²22. Kassada DS, Marcon SS, Pagliarini MA, Rossi M. Prevalência do uso de drogas de abuso por gestantes. Acta Paul Enferm 2013; 26:467-71.^,2323. Sakamoto LC, Malavasi A, Karasinb AL, Frajzinger RC, Araújo MR, Gebrim LH. Prevenção de gestações não planejadas com implante subdérmico em mulheres da Cracolândia, São Paulo. Reprod Clim 2015; 30:102-7.^,2424. Rocha PC, Alves MTSSB, Chagas DC, Silva AAM, Batista RFL, Silva RA. Prevalência e fatores associados ao uso de drogas ilícitas em gestantes da coorte BRISA. Cad Saúde Pública 2016; 32:e00192714.. Meanwhile, sociocultural studies feature the meanings and perceptions that the women and healthcare workers construct about the risks and living, labor, and health conditions ²⁶26. Bassuk EL, Weinreb L. Homeless pregnant women: two generations at risk. Am J Orthopsychiatry 1993; 63:348-57.^,2727. Bloom KC, Bednarzyk MS, Devitt D, Renault RA, Teaman V, Loock MV. Barriers to prenatal care for homeless pregnant women. J Obstet Gynecol Neonatal Nurs 2004; 33:428-35.^,2929. Leppo A. "Subutex is safe": perceptions of risk in using illicit drugs durin pregnancy. Int J Drug Policy 2012; 23:365-73..

The studies with a biomedical emphasis strive to locate the possible adverse obstetric and neonatal effects: abortion ²³23. Sakamoto LC, Malavasi A, Karasinb AL, Frajzinger RC, Araújo MR, Gebrim LH. Prevenção de gestações não planejadas com implante subdérmico em mulheres da Cracolândia, São Paulo. Reprod Clim 2015; 30:102-7., hemorrhages, anemia, fetal malformation, preterm birth ²⁷27. Bloom KC, Bednarzyk MS, Devitt D, Renault RA, Teaman V, Loock MV. Barriers to prenatal care for homeless pregnant women. J Obstet Gynecol Neonatal Nurs 2004; 33:428-35., low birthweight ²⁸28. Schempf AH, Strobino DM. Illicit drug use and adverse birth outcomes: is it drugs or context? J Urban Health 2008; 85:858-73., and others. The debate consists of establishing relations between living conditions, habits, and legal and illegal substance use and their effects on health, especially for the fetus/infant ²⁴24. Rocha PC, Alves MTSSB, Chagas DC, Silva AAM, Batista RFL, Silva RA. Prevalência e fatores associados ao uso de drogas ilícitas em gestantes da coorte BRISA. Cad Saúde Pública 2016; 32:e00192714.^,2828. Schempf AH, Strobino DM. Illicit drug use and adverse birth outcomes: is it drugs or context? J Urban Health 2008; 85:858-73.. But some studies also show that there is no definitively established causal nexus between substance use, gestational age, and the occurrence of negative outcomes ²³23. Sakamoto LC, Malavasi A, Karasinb AL, Frajzinger RC, Araújo MR, Gebrim LH. Prevenção de gestações não planejadas com implante subdérmico em mulheres da Cracolândia, São Paulo. Reprod Clim 2015; 30:102-7.^,2424. Rocha PC, Alves MTSSB, Chagas DC, Silva AAM, Batista RFL, Silva RA. Prevalência e fatores associados ao uso de drogas ilícitas em gestantes da coorte BRISA. Cad Saúde Pública 2016; 32:e00192714.^,2828. Schempf AH, Strobino DM. Illicit drug use and adverse birth outcomes: is it drugs or context? J Urban Health 2008; 85:858-73..

In some of these studies ²²22. Kassada DS, Marcon SS, Pagliarini MA, Rossi M. Prevalência do uso de drogas de abuso por gestantes. Acta Paul Enferm 2013; 26:467-71.^,2323. Sakamoto LC, Malavasi A, Karasinb AL, Frajzinger RC, Araújo MR, Gebrim LH. Prevenção de gestações não planejadas com implante subdérmico em mulheres da Cracolândia, São Paulo. Reprod Clim 2015; 30:102-7., the risk discourse is also associated with the services’ organization, indicating that homelessness and illicit drug use cause both individual harms to the health of the woman and the fetus/child and social harms such as growing expenses for health systems and an overload on the hospital bed occupancy rate and social assistance. In this context, one study ²⁵25. Gustavsson NS. Drug exposed infants and their mothers: facts, myths, and needs. Soc Work Health Care 1992; 16:87-100. recommends an industrial chain of toxicology tests for these women and their newborns (via meconium and the mother’s hair and urine) as a strategy to control risk factors related to drug use.

Another study ²³23. Sakamoto LC, Malavasi A, Karasinb AL, Frajzinger RC, Araújo MR, Gebrim LH. Prevenção de gestações não planejadas com implante subdérmico em mulheres da Cracolândia, São Paulo. Reprod Clim 2015; 30:102-7. compares the costs of low and high-risk childbirth and neonatal care with cost-benefits resulting from subdermal contraceptive implants used for three years, containing 68mg of etonogestrel, in a population of 106 women in the area known as “Cracolândia” (Crackland) in São Paulo. According to the authors ²³23. Sakamoto LC, Malavasi A, Karasinb AL, Frajzinger RC, Araújo MR, Gebrim LH. Prevenção de gestações não planejadas com implante subdérmico em mulheres da Cracolândia, São Paulo. Reprod Clim 2015; 30:102-7., investment in the prevention of unplanned pregnancies in homeless women and/or drug users is the best and cheapest option.

From another perspective, studies with a sociocultural approach ²⁶26. Bassuk EL, Weinreb L. Homeless pregnant women: two generations at risk. Am J Orthopsychiatry 1993; 63:348-57.^,2727. Bloom KC, Bednarzyk MS, Devitt D, Renault RA, Teaman V, Loock MV. Barriers to prenatal care for homeless pregnant women. J Obstet Gynecol Neonatal Nurs 2004; 33:428-35.^,2929. Leppo A. "Subutex is safe": perceptions of risk in using illicit drugs durin pregnancy. Int J Drug Policy 2012; 23:365-73. view risk factors as a social construction regulated by each social actor’s place of speech. Thus, healthcare workers and homeless women with (or without) a history of drug use tend to perceive risks differently ²⁹29. Leppo A. "Subutex is safe": perceptions of risk in using illicit drugs durin pregnancy. Int J Drug Policy 2012; 23:365-73..

For Bassuk & Weinreb ²⁶26. Bassuk EL, Weinreb L. Homeless pregnant women: two generations at risk. Am J Orthopsychiatry 1993; 63:348-57., the distribution of risks is markedly unequal. According to the authors, risk factors operate on the border of structural inequalities, and the bodies of poor black women receive the most frequent and intense impact from political, economic, and social decisions that maintain the risk factors’ historical reproduction.

In keeping with this view, Leppo ²⁹29. Leppo A. "Subutex is safe": perceptions of risk in using illicit drugs durin pregnancy. Int J Drug Policy 2012; 23:365-73. highlights that the biomedical discourse on drug use targets the female body on the streets via morality, where abstinence not only poses a risk to the mental health of these women but also carries a heavy demand, since to “stay clean” they would often have to break with significant social bonds and ties.

Leppo ²⁹29. Leppo A. "Subutex is safe": perceptions of risk in using illicit drugs durin pregnancy. Int J Drug Policy 2012; 23:365-73. emphasizes that for the women, abstinence does not solve the risks they face daily in their social context (poverty, racism, patriarchy, violence) and that their concerns include the possibility that the baby will present withdrawal symptoms and interventions leading to their separation from the child. Thus, these women tend not to avoid seeking healthcare and social services.

Data reported by Leppo ²⁹29. Leppo A. "Subutex is safe": perceptions of risk in using illicit drugs durin pregnancy. Int J Drug Policy 2012; 23:365-73. break with narratives that tend to view homeless women as negligent due to their low adherence to prenatal care programs, corroborating findings by Bloom et al. ²⁷27. Bloom KC, Bednarzyk MS, Devitt D, Renault RA, Teaman V, Loock MV. Barriers to prenatal care for homeless pregnant women. J Obstet Gynecol Neonatal Nurs 2004; 33:428-35. for whom barriers to prenatal care constitute important risk factors for adverse pregnancy and childbirth events for these women.

Discourses on prenatal care

The debate on prenatal care in homeless women appears in 2 of the 21 studies ³¹31. Araújo MAS, Santos AAP, Lúcio IML, Tavares CM, Fidélis EPB. O contexto da gestante na situação de rua e vulnerabilidade: seu olhar sobre o pré-natal. Rev Enferm UFPE On Line 2017; 11 Suppl 10:4103-10.^,3232. Beal AC, Redlener I. Enhancing perinatal outcome in homeless women: the challenge of providing comprehensive healt care. Semin Perinatol 1995; 19:307-13.. Although the studies were produced in different contexts, the first in Brazil and the second in the United States, they converge in the idea that motherhood for these women poses a series of challenges for healthcare personnel and systems.

There is a consensus among these authors ³¹31. Araújo MAS, Santos AAP, Lúcio IML, Tavares CM, Fidélis EPB. O contexto da gestante na situação de rua e vulnerabilidade: seu olhar sobre o pré-natal. Rev Enferm UFPE On Line 2017; 11 Suppl 10:4103-10.^,3232. Beal AC, Redlener I. Enhancing perinatal outcome in homeless women: the challenge of providing comprehensive healt care. Semin Perinatol 1995; 19:307-13. that prenatal care, when well-managed, i.e., timely enough for early diagnosis of the pregnancy, with serological testing and receptiveness to the women’s needs, can be a device of care capable of controlling and reducing the health risk for the pregnant woman and fetus.

For the authors ³¹31. Araújo MAS, Santos AAP, Lúcio IML, Tavares CM, Fidélis EPB. O contexto da gestante na situação de rua e vulnerabilidade: seu olhar sobre o pré-natal. Rev Enferm UFPE On Line 2017; 11 Suppl 10:4103-10.^,3232. Beal AC, Redlener I. Enhancing perinatal outcome in homeless women: the challenge of providing comprehensive healt care. Semin Perinatol 1995; 19:307-13., these women are marked by a wide range of demands which often extend beyond the health sector, including during prenatal care. These challenges vary from issuing personal identification papers to the supply of living facilities for the mother and infant and in some cases the entire family.

The authors ³¹31. Araújo MAS, Santos AAP, Lúcio IML, Tavares CM, Fidélis EPB. O contexto da gestante na situação de rua e vulnerabilidade: seu olhar sobre o pré-natal. Rev Enferm UFPE On Line 2017; 11 Suppl 10:4103-10.^,3232. Beal AC, Redlener I. Enhancing perinatal outcome in homeless women: the challenge of providing comprehensive healt care. Semin Perinatol 1995; 19:307-13. also agree on the idea that the way services organize to respond to the challenges for homeless women can be crucial for better pregnancy outcomes, not only from the biomedical point of view, but also to guarantee the women’s rights and those of their children.

Discussing the organization of prenatal care for homeless women, Araújo et al. ³¹31. Araújo MAS, Santos AAP, Lúcio IML, Tavares CM, Fidélis EPB. O contexto da gestante na situação de rua e vulnerabilidade: seu olhar sobre o pré-natal. Rev Enferm UFPE On Line 2017; 11 Suppl 10:4103-10. focus on prenatal care consultations by nursing staff in the Street Outreach Clinic. Meanwhile, Beal & Redlener ³²32. Beal AC, Redlener I. Enhancing perinatal outcome in homeless women: the challenge of providing comprehensive healt care. Semin Perinatol 1995; 19:307-13. discuss the implications of prenatal care for controlling and reducing risk factors that produce adverse effects on the women pregnancies, such as poverty, malnutrition, and precarious housing.

Araújo et al. ³¹31. Araújo MAS, Santos AAP, Lúcio IML, Tavares CM, Fidélis EPB. O contexto da gestante na situação de rua e vulnerabilidade: seu olhar sobre o pré-natal. Rev Enferm UFPE On Line 2017; 11 Suppl 10:4103-10. (p. 4105-6) problematize healthcare practices based on homeless women’s place of speech and contend that “prenatal care can control the risk factors leading to gestational complications, besides allowing detection and timely treatment of complications, contributing to more favorable perinatal and maternal outcomes”. However, they warn that “prenatal care, no matter how many visits, does not guarantee adequate care” ³¹31. Araújo MAS, Santos AAP, Lúcio IML, Tavares CM, Fidélis EPB. O contexto da gestante na situação de rua e vulnerabilidade: seu olhar sobre o pré-natal. Rev Enferm UFPE On Line 2017; 11 Suppl 10:4103-10. (p. 4106), so prenatal care initiated late tends to favor the occurrence of adverse birth outcomes (prematurity, low birthweight, and fetal and/or maternal death). For the authors ³¹31. Araújo MAS, Santos AAP, Lúcio IML, Tavares CM, Fidélis EPB. O contexto da gestante na situação de rua e vulnerabilidade: seu olhar sobre o pré-natal. Rev Enferm UFPE On Line 2017; 11 Suppl 10:4103-10., designing the (re)organization of maternal-child services from the point of view of these women means acknowledging how they feel at the services, which treatments are offered, and the reasons contributing to their failure to seek the services or to drop out.

The authors ³¹31. Araújo MAS, Santos AAP, Lúcio IML, Tavares CM, Fidélis EPB. O contexto da gestante na situação de rua e vulnerabilidade: seu olhar sobre o pré-natal. Rev Enferm UFPE On Line 2017; 11 Suppl 10:4103-10. also state that the ideals of the Brazilian National Humanization Policy (PNH) favor the perspective of place of speech and sympathetic listening, shifting the dropout indicator from explanations centered on lifestyle to the understanding that failure to return to the services may be due to discouragement, but also “because the women have been victims of prejudice in the institution’s care” ³¹31. Araújo MAS, Santos AAP, Lúcio IML, Tavares CM, Fidélis EPB. O contexto da gestante na situação de rua e vulnerabilidade: seu olhar sobre o pré-natal. Rev Enferm UFPE On Line 2017; 11 Suppl 10:4103-10. (p. 4106).

The authors ³¹31. Araújo MAS, Santos AAP, Lúcio IML, Tavares CM, Fidélis EPB. O contexto da gestante na situação de rua e vulnerabilidade: seu olhar sobre o pré-natal. Rev Enferm UFPE On Line 2017; 11 Suppl 10:4103-10. thus view prenatal care not only as the performance of laboratory tests and immunization, but as a moment of listening. From this perspective, (re)organization of healthcare practices wagers on prenatal care as a time of bonding between healthcare personnel and “high-risk pregnant women that should receive special care, with the likelihood of acute intoxication leading up to the moment of childbirth” ³¹31. Araújo MAS, Santos AAP, Lúcio IML, Tavares CM, Fidélis EPB. O contexto da gestante na situação de rua e vulnerabilidade: seu olhar sobre o pré-natal. Rev Enferm UFPE On Line 2017; 11 Suppl 10:4103-10. (p. 4106).

Another point of convergence between the two studies ³¹31. Araújo MAS, Santos AAP, Lúcio IML, Tavares CM, Fidélis EPB. O contexto da gestante na situação de rua e vulnerabilidade: seu olhar sobre o pré-natal. Rev Enferm UFPE On Line 2017; 11 Suppl 10:4103-10.^,3232. Beal AC, Redlener I. Enhancing perinatal outcome in homeless women: the challenge of providing comprehensive healt care. Semin Perinatol 1995; 19:307-13. is the acknowledgement that these pregnancies are produced in situations of extreme social vulnerability. Organizing this prenatal care requires the production of more than basic or routine care. For Beal & Redlener ³²32. Beal AC, Redlener I. Enhancing perinatal outcome in homeless women: the challenge of providing comprehensive healt care. Semin Perinatol 1995; 19:307-13., there is a structural level that hinders homeless women’s access to health services, and when they do come, more than routine care must be provided. To respond to the challenges faced by homeless women, prenatal care must address not only the health issue itself, but the social context in which these motherhoods are produced: “familial dysfunction, poor planning abilities, or substance abuse” ³²32. Beal AC, Redlener I. Enhancing perinatal outcome in homeless women: the challenge of providing comprehensive healt care. Semin Perinatol 1995; 19:307-13. (p. 308).

These same authors thus wager politically ³¹31. Araújo MAS, Santos AAP, Lúcio IML, Tavares CM, Fidélis EPB. O contexto da gestante na situação de rua e vulnerabilidade: seu olhar sobre o pré-natal. Rev Enferm UFPE On Line 2017; 11 Suppl 10:4103-10.^,3232. Beal AC, Redlener I. Enhancing perinatal outcome in homeless women: the challenge of providing comprehensive healt care. Semin Perinatol 1995; 19:307-13. on the reorganization of healthcare, since they understand the need to acknowledge that homeless women have diverse needs and that the reasons for these women’s homelessness differ, as do the ways they relate to “the street”.

Rights of women and of fetuses/children

The debate on the rights of homeless pregnant women appeared in 6 of the 21 studies ³³33. Garcia SA. Drug addiction and mother/child welfare. J Leg Med 1992; 13:129-203.^,3434. Olsen A. Punishing parents: child removal in the context of drug use. Drug Alcohol Rev 2014; 34:27-30.^,3535. Maher L, Curtis R. Women on the edge of crime: crack cocaine and the changing contexts of street-level sex work in New York City. Crime Law Soc Change 1992; 18:221-58.^,3636. Cohen LB. Informing consent: medical malpractice and the criminalization of pregnancy. Mich Law Rev 2018; 116:1297-316.^,3737. Poland ML, Dombrowskia MP, Agerb WJ, Sokol RJ. Punishing preganant drug users: enhancing the flight from care. Drug Alcohol Depend 1993; 31:199-203.^,3838. Moss KL. Substance dependency durin pregnancy: the limits of the law. Womens Health Issues 1991; 1:120-6., all international. This does not mean that these discussions are not taking place in Brazil. There is important research work to back this debate, as mentioned with the United Network, but it was not located in the integrative review.

The studies ³³33. Garcia SA. Drug addiction and mother/child welfare. J Leg Med 1992; 13:129-203.^,3434. Olsen A. Punishing parents: child removal in the context of drug use. Drug Alcohol Rev 2014; 34:27-30.^,3535. Maher L, Curtis R. Women on the edge of crime: crack cocaine and the changing contexts of street-level sex work in New York City. Crime Law Soc Change 1992; 18:221-58.^,3636. Cohen LB. Informing consent: medical malpractice and the criminalization of pregnancy. Mich Law Rev 2018; 116:1297-316.^,3737. Poland ML, Dombrowskia MP, Agerb WJ, Sokol RJ. Punishing preganant drug users: enhancing the flight from care. Drug Alcohol Depend 1993; 31:199-203.^,3838. Moss KL. Substance dependency durin pregnancy: the limits of the law. Womens Health Issues 1991; 1:120-6. describe different legal understandings of the issue and the ways they are expressed in biomedical practices and in routine healthcare and social services. They are based on the acknowledgement of a tension between the rights of homeless mothers and those of fetuses/infants, with a certain consensus that the central issue is not only an analysis of the State’s role, but of interests pertaining to these women’s bodies and their offspring. Here, the debate on motherhood and drug use overlaps the discussions on motherhood and homelessness.

Garcia ³³33. Garcia SA. Drug addiction and mother/child welfare. J Leg Med 1992; 13:129-203. problematizes the tension between individual safeguards and the State’s role, calling attention to controversial issues in the scientific literature. For the author, it is still not clear whether drug use by these women is a medical issue or one of public security, or whether these pregnant women should be considered criminals due to this drug use and the potential harms to the fetus. For the author, if pregnancy in these women is considered a social problem, it remains to be determined when the State should intervene to guarantee rights (which ones, and of whom).

“[The debate on] drug addiction during pregnancy raises the question of at what point during gestation the state has an interest compelling enough to warrant intervention to protect the fetus. However, the additional issue of whether the unborn have a right to be born healthy compounds the problem of determining when the state should step in to protect the health of the unborn” ³³33. Garcia SA. Drug addiction and mother/child welfare. J Leg Med 1992; 13:129-203. (p. 136).

For Garcia ³³33. Garcia SA. Drug addiction and mother/child welfare. J Leg Med 1992; 13:129-203., there is a global trend to create legal provisions that classify drug use during pregnancy as evidence of neglect and/or child abuse. These provisions are anchored in rationalities that juxtapose the women’s rights with those of the fetus or infant and are centered on this division, relegating the “need for help” for these women and inflating the rights of the fetus or infant. According to this logic, such guarantees can only be achieved if the State takes custody of the baby.

For Olsen ³⁴34. Olsen A. Punishing parents: child removal in the context of drug use. Drug Alcohol Rev 2014; 34:27-30., the standard State response centered on punitive norms for health issues such as drug use during pregnancy undermines the debate on issues that permeate the production of these motherhoods: “If our aim is to prevent harms to children, then our primary focus should be on supporting, not forcing, women and their families through drug treatment and social services options” ³⁴34. Olsen A. Punishing parents: child removal in the context of drug use. Drug Alcohol Rev 2014; 34:27-30. (p. 29). The author suggests that the laws backing criminalization of homeless women’s motherhood operate on the separation between the body of the woman/mother/drug user, viewed as perpetrator of the crime, and the body of the child, seen as victim of her drug use.

According to Maher & Curtis ³⁵35. Maher L, Curtis R. Women on the edge of crime: crack cocaine and the changing contexts of street-level sex work in New York City. Crime Law Soc Change 1992; 18:221-58., this form of policymaking produces psychological traumas in the mother-infant relationship and increases the costs of social services (institutions receiving the women and children). By focusing on damage control, the State’s responses shift the attention from understanding how the organization of class, race, and gender structure operates on homeless women’s bodies and ultimately bypasses the need for a national health policy.

Cohen ³⁶36. Cohen LB. Informing consent: medical malpractice and the criminalization of pregnancy. Mich Law Rev 2018; 116:1297-316. studied toxicology tests performed during pregnancy and found that women were tested without their consent or knowledge of the test results, with reports that when women failed to waive their patient-physician confidentiality rights, the newborns were taken from them and put up for adoption.

For the author ³⁶36. Cohen LB. Informing consent: medical malpractice and the criminalization of pregnancy. Mich Law Rev 2018; 116:1297-316., the idea that homeless women pose a threat to their infants is grounded in the belief that drug use produces inferior offspring, capable of overloading health, social, and educational services. Infant protection notwithstanding, the discourse that it is necessary to safeguard the children makes the enforcement of punitive norms unacceptable, since it acts as an institutional violation of rights and serves as justification to suspend any women’s rights ³⁶36. Cohen LB. Informing consent: medical malpractice and the criminalization of pregnancy. Mich Law Rev 2018; 116:1297-316.. The author contends that such strategies create breaks and mistrust in the bonds between healthcare personnel and women.

These intersections between biomedical and legal knowledge and practices are expressed in the normative provisions. Cohen ³⁶36. Cohen LB. Informing consent: medical malpractice and the criminalization of pregnancy. Mich Law Rev 2018; 116:1297-316. notes that the denial of women’s autonomy over their bodies, even when they are pregnant, and toxicology testing without their consent and knowledge of the effects are not only misogynous but represent medical neglect, of which the perpetrators should be held accountable.

Poland et al. ³⁷37. Poland ML, Dombrowskia MP, Agerb WJ, Sokol RJ. Punishing preganant drug users: enhancing the flight from care. Drug Alcohol Depend 1993; 31:199-203., based on the women’s reports, discuss that punitive laws function for them as an impediment to the use of prenatal healthcare and social services. Thus, homeless women are more likely not to adhere to care “for fear of incarceration and loss of their children” ³⁷37. Poland ML, Dombrowskia MP, Agerb WJ, Sokol RJ. Punishing preganant drug users: enhancing the flight from care. Drug Alcohol Depend 1993; 31:199-203. (p. 202) This debunks the widespread belief that punishing women’s drug use during pregnancy contributes to abstinence.

Meanings of motherhood

The debate on motherhood as a possibility for other meanings for homeless women appears in 5 of the 21 studies, three of which published in Brazil ³⁹39. Costa SL, Vida CPC, Gama IA, Locatelli NT, Karam BJ. Gestantes em situação de rua no Município de Santos - SP: reflexões e desafios para as políticas públicas. Saúde Soc 2015; 24:1089-102.^,4040. Oliveira ES. "Por sua culpa, sua tão grande culpa": um estudo sobre o processo de naturalização, responsabilização e culpabilização das mães dos meninos e meninas em situação de rua [Tese de Doutorado]. São Paulo: Pontifícia Universidade Católica de São Paulo; 2015.^,4141. Almeida DJR, Quadros LCT. A pedra que pariu: narrativas e práticas de aproximação de gestantes em situação de rua e usuárias de crack na cidade do Rio de Janeiro. Pesqui Prát Psicossociais 2016; 11:225-37. and two in the international context ⁴²42. McClelland GT, Newell R. A qualitative study of the experiences of mothers involved in street-based prostitution and problematic substance use. J Res Nurs 2008; 13:437-47.^,4343. King KE, Ross LE, Bruno TL, Erickson PG. Identity work among street-involved young mothers. J Youth Stud 2009; 12:139-49..

These studies ³⁹39. Costa SL, Vida CPC, Gama IA, Locatelli NT, Karam BJ. Gestantes em situação de rua no Município de Santos - SP: reflexões e desafios para as políticas públicas. Saúde Soc 2015; 24:1089-102.^,4040. Oliveira ES. "Por sua culpa, sua tão grande culpa": um estudo sobre o processo de naturalização, responsabilização e culpabilização das mães dos meninos e meninas em situação de rua [Tese de Doutorado]. São Paulo: Pontifícia Universidade Católica de São Paulo; 2015.^,4141. Almeida DJR, Quadros LCT. A pedra que pariu: narrativas e práticas de aproximação de gestantes em situação de rua e usuárias de crack na cidade do Rio de Janeiro. Pesqui Prát Psicossociais 2016; 11:225-37.^,4242. McClelland GT, Newell R. A qualitative study of the experiences of mothers involved in street-based prostitution and problematic substance use. J Res Nurs 2008; 13:437-47.^,4343. King KE, Ross LE, Bruno TL, Erickson PG. Identity work among street-involved young mothers. J Youth Stud 2009; 12:139-49. contain common core meanings that consider the possibility of other ways of living one’s life based on the experience of motherhood.

In these studies, so long as motherhood is wanted, it can represent a turning point in the lives of these women, potentially triggering the building of other life projects in which leaving the streets and interruption of drug use are goals. Still, authors such as Costa et al. ³⁹39. Costa SL, Vida CPC, Gama IA, Locatelli NT, Karam BJ. Gestantes em situação de rua no Município de Santos - SP: reflexões e desafios para as políticas públicas. Saúde Soc 2015; 24:1089-102. and King et al. ⁴³43. King KE, Ross LE, Bruno TL, Erickson PG. Identity work among street-involved young mothers. J Youth Stud 2009; 12:139-49. acknowledge that the women’s daily struggle for survival become a hurdle to shifting their intentions from the field of wishes to planning effective strategies.

Oliveira ⁴⁰40. Oliveira ES. "Por sua culpa, sua tão grande culpa": um estudo sobre o processo de naturalização, responsabilização e culpabilização das mães dos meninos e meninas em situação de rua [Tese de Doutorado]. São Paulo: Pontifícia Universidade Católica de São Paulo; 2015. also notes that while the desire for motherhood may favor building other meanings and life projects, such desire alone does not guarantee the projects’ long-term sustainability, since generational inequalities weigh on these women.

Oliveira ⁴⁰40. Oliveira ES. "Por sua culpa, sua tão grande culpa": um estudo sobre o processo de naturalização, responsabilização e culpabilização das mães dos meninos e meninas em situação de rua [Tese de Doutorado]. São Paulo: Pontifícia Universidade Católica de São Paulo; 2015. has used the concept of “street mothers” to refer to women/mothers who want to bear and raise their children but live in a context of profound social unprotectedness. “Street mother” is a metaphor that expresses social gender contradictions ⁹9. Santos GC, Constantino P, Schenker M, Rodrigues LB. O consumo de crack por mulheres: uma análise sobre os sentidos construídos por profissionais de consultórios na rua da cidade do Rio de Janeiro, Brasil. Ciênc Saúde Colet 2020; 25:3795-808., since it is socially expected of such women that they will quit their drug use on behalf of their “offspring” and become domiciled, assuming the provision of their children’s wellbeing, even without structural conditions such as housing policies to favor them. According to Oliveira ⁴⁰40. Oliveira ES. "Por sua culpa, sua tão grande culpa": um estudo sobre o processo de naturalização, responsabilização e culpabilização das mães dos meninos e meninas em situação de rua [Tese de Doutorado]. São Paulo: Pontifícia Universidade Católica de São Paulo; 2015., since the responsibility for providing the children’s social wellbeing falls on the shoulders of the homeless women or “street mothers”, the father’s role is nearly always ignored.

In the international context, King et al. ⁴³43. King KE, Ross LE, Bruno TL, Erickson PG. Identity work among street-involved young mothers. J Youth Stud 2009; 12:139-49. analyzed homeless women’s discursive practices and concluded that these motherhoods may represent a “turning point in the lives”, so long as the political and social conditions and not only lifestyles favor it. The authors further suggest that the arrival of a child may represent the possibility of the mother projecting herself into the future. The women participating in the study reported that “cutting off contact with their friends, and not hanging out downtown anymore, as an important part of their move away from the street and into a parenting role” ⁴³43. King KE, Ross LE, Bruno TL, Erickson PG. Identity work among street-involved young mothers. J Youth Stud 2009; 12:139-49. (p. 145).

Almeida & Quadros ⁴¹41. Almeida DJR, Quadros LCT. A pedra que pariu: narrativas e práticas de aproximação de gestantes em situação de rua e usuárias de crack na cidade do Rio de Janeiro. Pesqui Prát Psicossociais 2016; 11:225-37. presented similar findings, demonstrating that the women they interviewed basically realized that the context of the street and drug use did not favor their children’s physical, social, and psychological development.

Homeless women’s history is marked by encounters with violence, premature losses, unprotected sex, mental health issues, and difficulties in access to contraceptive methods. For Almeida & Quadros ⁴¹41. Almeida DJR, Quadros LCT. A pedra que pariu: narrativas e práticas de aproximação de gestantes em situação de rua e usuárias de crack na cidade do Rio de Janeiro. Pesqui Prát Psicossociais 2016; 11:225-37., such experiences permeate the ways they exercise motherhood, far from the “gold standard” found in the literature and acknowledged as ideal.

McClelland & Newell ⁴²42. McClelland GT, Newell R. A qualitative study of the experiences of mothers involved in street-based prostitution and problematic substance use. J Res Nurs 2008; 13:437-47. state that drug use is not necessarily a predictor of negligent, irresponsible, and lax motherhood, although acknowledging that it can favor behaviors that expose the children to unnecessary risks. Importantly, the literature has reported cases of women/mothers that tend to orient their drug choice and the development of strategies so that drug use will not pose a threat to their children.

As cited by Almeida & Quadros ⁴¹41. Almeida DJR, Quadros LCT. A pedra que pariu: narrativas e práticas de aproximação de gestantes em situação de rua e usuárias de crack na cidade do Rio de Janeiro. Pesqui Prát Psicossociais 2016; 11:225-37. (p. 231), “Maria dos Anjos reported that she does not use alcohol or cigarettes, stating that these habits are not good for her children. She chooses the drugs she consumes on the condition that she does not lose consciousness, because her greatest fear is that something could happen to the children and that she wouldn’t be able to care for them”.

By analyzing the life stories of three women, Almeida & Quadros ⁴¹41. Almeida DJR, Quadros LCT. A pedra que pariu: narrativas e práticas de aproximação de gestantes em situação de rua e usuárias de crack na cidade do Rio de Janeiro. Pesqui Prát Psicossociais 2016; 11:225-37. stated that since they want the best for their children, they are constantly negotiating the exercise of their maternal roles “as best as they can” ⁴¹41. Almeida DJR, Quadros LCT. A pedra que pariu: narrativas e práticas de aproximação de gestantes em situação de rua e usuárias de crack na cidade do Rio de Janeiro. Pesqui Prát Psicossociais 2016; 11:225-37. (p. 235). According to the authors, these three mothers wish better “fates” or “futures” than their own for their children. The study shows that even living on the fringes and exercising other ways of showing their affection, protection, and care, the women participating in the study “are overflowing with feelings that shape another future for the woman-mother” ⁴¹41. Almeida DJR, Quadros LCT. A pedra que pariu: narrativas e práticas de aproximação de gestantes em situação de rua e usuárias de crack na cidade do Rio de Janeiro. Pesqui Prát Psicossociais 2016; 11:225-37. (p. 236).

Concerning motherhood as a possibility for building new life projects, Costa et al. ³⁹39. Costa SL, Vida CPC, Gama IA, Locatelli NT, Karam BJ. Gestantes em situação de rua no Município de Santos - SP: reflexões e desafios para as políticas públicas. Saúde Soc 2015; 24:1089-102. suggest that some homeless women/mothers did not want the pregnancy, but did not report condom use, which according to the authors indicates that the women assumed pregnancy as a daily possibility. According to the study ³⁹39. Costa SL, Vida CPC, Gama IA, Locatelli NT, Karam BJ. Gestantes em situação de rua no Município de Santos - SP: reflexões e desafios para as políticas públicas. Saúde Soc 2015; 24:1089-102., many women reported dissatisfaction when they discovered the pregnancy but became happier over time. The authors call attention to the fact that accepting the pregnancy does not mean establishing affective bonds with it or the desire to keep and raise the child.

“There is a protective bond, with different variations: some turn to institutions and persons that can raise their child under better conditions: others say that regardless of their current situation, they want to keep and raise their child; others have still not displayed bonding, which leads to abandoning the child” ³⁹39. Costa SL, Vida CPC, Gama IA, Locatelli NT, Karam BJ. Gestantes em situação de rua no Município de Santos - SP: reflexões e desafios para as políticas públicas. Saúde Soc 2015; 24:1089-102. (p. 1097).

The observation of various possible ways of exercising the mother’s role suggests a perception that living on the streets with a history of drug use does not favor caring for a child. It further suggests that when deciding to “turn over” the infant to an institution or someone close with whom they are often able to maintain some connection to their children, these women do so not because they do not love their children, but precisely because they believe they are doing the best for them.

Final remarks

The analysis of the discursive production of science concerning homeless women’s experiences with motherhood allowed the identification of contradictions, deletions, and issues that bring the issue to the surface. Identification of the core meanings in the studies allowed analyzing how the different forms of knowledge (biomedical, legal, and socio-anthropological) produce scientific discourses and offer distinct but complementary ways of viewing the topic, constituting a discursive corpus that often becomes the hegemonic discourse of protection and care for the fetus/infant, while also signaling, although marginally, the implications of social inequalities and the challenges for guaranteeing homeless women’s right to motherhood.

The studies acknowledge homeless women’s pregnancies as a State matter and find a centrality in the idea of protection for the fetus/child, to the detriment of understanding of the life context of these women and their pregnancies. Most of the studies avoid any discussion of male chauvinism, racism, and poverty, sometimes mobilizing race, gender, and poverty as descriptive variables, erasing the sociological dimensions of these concepts and the capacity to discuss power relations as keys for understanding the life history of these women and their motherhoods.

Despite this void, which is not by chance or even a mere coincidence, some studies highlight the abyssal line operating on women’s bodies, selecting those that are “authorized (and urged)” to reproduce and those placed under regimes of constant surveillance to be controlled and even prevented from bearing descendants. These are often homeless or slum-dwelling women and/or psychoactive substance users, black and poor.

When a homeless or drug-using woman breaks the law or infringes the norm, her parental power is revoked, justified by a series of legal propositions grounded in the idea of risks to the infant, addressed here specifically in the studies from the group “health risks for the woman and the fetus/child”. The risk discourse is mobilized to justify interventions in the bodies of these women and to underpin the State’s option, in its legal and social assistance form, through advocacy for the more vulnerable fetus/child. Thus, the hegemony of biomedical risk discourse hides the fact that separating these women from their children is contingent on the condition of poverty and the weakness of these women´s social, community, and family networks.

This debate addresses the biomedical risks (and especially the biological ones). It is the perception of this risk that makes the inscription of these bodies possible in the political domain, shifting these women´s pregnancy from the private family sphere to a State matter that ultimately decides who prevails, and which rights: those of the homeless woman or those of the fetus/child.

By prioritizing the biological perspective, the biomedical discourse on risk shifts the solutions to problems experienced by these women and their infants from collective strategies such as policies to reduce inequalities (based on gender, race, poverty, housing, food, etc.) to individualizing strategies such as abstinence, medical procedures, laboratory tests, and suspension of parental power.

In the risk proposition, the association with drugs proved constant, even without explicit use of the term “drugs” in the search strategy. This is another aspect that reinforces the idea, both derogatory and mistaken, that discriminates, excludes, and associates homelessness with drug consumption.

A counterpoint to the risk proposition appears in the discourse on prenatal care, although only two studies were found. At both the national and international levels, the search identified strategies with approaches to (and recognition of) specificities involved in prenatal care for these women, as well as the barriers created by structural issues. The studies acknowledge that there are risks in homeless women’s motherhood, but that prenatal care can be mobilized as a technology of care capable of reducing risks, in a wager on the organization of humanized, territorialized inter-sector care, operated by soft and soft-hard technologies. Even so, the studies underscore that prenatal care, regardless of whether it is performed in timely and routine fashion, is not necessarily an indicator of homeless women’s future mothering capacity.

The literature indicates that solutions to tensions between the women’s rights and those of the fetus/child involve coercion/punishment and the mandatory supply of assistance focused on the infant’s well-being. Santos et al. ⁹9. Santos GC, Constantino P, Schenker M, Rodrigues LB. O consumo de crack por mulheres: uma análise sobre os sentidos construídos por profissionais de consultórios na rua da cidade do Rio de Janeiro, Brasil. Ciênc Saúde Colet 2020; 25:3795-808. call attention to the fact even in health services in the SUS, oriented by altruistic and humanitarian values, homeless and drug-using women are stigmatized and blamed for their condition of poverty and drug use. The authors indicate that the prevailing ideal in the services’ organization is that of housewife, good wife, and wholesome mother.

In this case, despite all possible good intentions toward the fetus/child or even the mother, such practices may create other situations of violence besides those already present in the context of homelessness and in these women’s life histories ³3. Lima MS. A quem pertence essa gravidez? Reflexões sobre a maternidade/maternagem de mulheres que fazem uso de drogas e as agentes do estado [Dissertação de Mestrado]. Rio de Janeiro: Universidade do Estado do Rio de Janeiro; 2018.. The contradiction of these practices is that they produce the “perversity of ‘doing good’” ¹⁹19. Ferla AA, Jorge A, Merhy E. Separação compulsória de mães e seus filhos: quando a lei e a cidadania se confrontam. Saúde Redes 2018; 4 Suppl 1:5-8. in which human rights clash with the limits of laws.

In the wake of these contradictions, there is an important contribution by studies that denounce the serious violations these women suffer and the need to place limits on the State’s actions to prevent it from committing abuses in its interventions. The studies show that criminalization of these motherhoods has been a global trend in which the expansion of “fetal/infant” rights means a cutback in the women’s rights, to the point that homeless women avoid using social and health services.

Thus, “Whose baby is this?”, the opening question in the article’s title, is not a simple one. The answer usually requires complex linkage between profoundly interconnected dimensions of human life, ranging from macropolitical processes that sustain the reproduction of structural conditions permeating ways of life on the street, such as poverty, racism, and patriarchy, to subjective processes related to the meanings of motherhood and homelessness in the lives of these women. An ethical and humanitarian imperative is to conceive other modes of care, grounded in a human rights perspective, so that care for the fetus/child is not translated as violence against the women.

Acknowledgments

The authors wish to thank the Brazilina National Research Council (CNPq), the Program for Academic Excellence of the Brazilian Graduate Studies Coordinating Board (Proex/CAPES), and the Grade 10 Scholarship Program of the Rio de Janeiro State Research Support Foundation (FAPERJ) for the PhD scholarship in Public Health to conduct the study.

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