ARTÍCULO ORIGINAL / ORIGINAL ARTICLE/ ARTIGO ORIGINAL

Exclusive breastfeeding: motivations and disincentives for nursing mothers in Eldorado do Sul, Brazil

Lactancia materna exclusiva: motivaciones y desmotivaciones de las madres lactantes de Eldorado do Sul, Brasil

Aleitamento materno exclusivo. Motivações e desmotivações das nutrizes de Eldorado do Sul (Brasil)

Juliana Machado Schardosim¹; Petronila Libana Rauber Cechim²

¹RN, Master Universidade de Brasília, Brasília, DF - Brazil. email: jumachadoju@hotmail.com.

²RN, Master. Professor UNISINOS, Sao Leopoldo, RS - Brazil. email: plcechin@unisinos.br.

Receipt date: Oct 30, 2012. Approval date: Aug 20, 2013.

Article linked to research: Aleitamento materno exclusivo. Motivações e desmotivações das nutrizes de Eldorado do Sul.

Subventions: none.

Conflicts of interest: none.

ABSTRACT

Objective. Describing the motivations and disincentives that influence adherence to exclusive breastfeeding until children's six months of life in the town of Eldorado do Sul (Brazil). Methodology. A descriptive qualitative exploratory study. Between October and December/2009 it were interviewed 25 mothers of children aged from six to 18 months. Results. Three categories emerged from motivations - relationship of human milk with health and child nutrition, practicality and economy, and enjoyment and promotion of mother-infant bond; and three from disincentives - sudden decrease of milk with no apparent cause, working outside the home, and nipple trauma. Conclusion. The decision of exclusive breastfeeding until the child's six months of life involves a group of factors that the mother has to face during lactation

Key words: breast feeding; obstetrical nursing; weaning.

RESUMEN

Objetivo. Describir las motivaciones y desmotivaciones que influencian la adhesión a la lactancia materna exclusiva hasta los seis meses de vida del niño en el municipio de Eldorado do Sul (Brasil). Metodología. Investigación exploratoria descriptiva cualitativa. Se entrevistaron, de octubre a diciembre de 2009, a 25 madres de niños de 6 a 18 meses de vida. Resultados. Emergieron tres categorías de motivaciones: la leche humana y la salud y nutrición del niño, practicidad y economía, y placer y promoción del vínculo madre-bebé; y tres de desmotivaciones: diminución brusca de la leche sin causa aparente, el trabajo fuera del hogar, y problemas con los senos y los pezones. Conclusión. La decisión de amamantar al niño menor de seis meses envuelve un conjunto de factores que debe enfrentar la madre durante la lactancia.

Palabras clave: lactancia materna; enfermería obstétrica; destete.

RESUMO

Objetivo. Descrever as motivações e desmotivações que influenciam a adesão à lactância materna exclusiva até os 6 meses de vida do menino no município de Eldorado do Sul (Brasil). Metodologia. Investigação exploratória descritiva qualitativa. Entrevistaram-se de outubro a dezembro de 2009 a 25 mães de meninos de 6 a 18 meses de vida. Resultados. Emergiram três categorias de motivações -o leite humano e a saúde e nutrição do menino, praticidade e economia, e, prazer e promoção do vínculo mãe-bebê- e três de desmotivações - diminuição brusca do leite sem causa aparente, o trabalho fora do lar, e, problemas com os seios e os mamilos-. Conclusão. A decisão de amamentar exclusivamente ao menino menor de seis meses envolve um conjunto de fatores que deve enfrentar a mãe durante a lactância.

Palavras chaves: aleitamento materno; enfermagem obstétrica; desmame.

INTRODUCTION

Breastfeeding (BF) is a widely discussed topic in nursing. It is a practice with numerous benefits for the mother-child binomial. A successful BF is not dependant only on the willingness and availability of the nursing mother; assistance and guidance from health professionals is also important, from prenatal care to childbirth and recovery, until the return of the nursing mother and her baby to the Basic Health Unit. The prevalence of exclusive and non-exclusive BF in Brazil in 1999 was, respectively, of 53.1% and 88% in the first 30 days and of 9.7% and 72.9% between 151 and 180 days of the child's life.^1,2 In the South region of Brazil the prevalence of exclusive and non-exclusive BF was respectively 64.3% and 82.3% in the first 30 days and 12.9% and 65.2% between 151 and 180 days.^1-2 A study conducted by the Ministry of Health of Brazil in 2009 showed prevalence of exclusive breastfeeding in babies under six months of 41% in Brazil, and of 43.5% in the South region of the country.³ It is observed, therefore, that throughout these ten years, even with the creation of programs and public policies of attention and encouragement to BF as well as incentives in the media, breastfeeding rates have increased but still remain below 50%. In this scenario it is important to investigate the reasons that lead these mothers to abandon breastfeeding in order to develop actions aimed at the causes.

The Ministry of Health in its National Policy for the Promotion, Protection and Support of Breastfeeding has some strategies: rede Amamenta Brasil (Breastfeeding network), Brazilian network of human milk bank, Baby friendly hospital initiative, legal protection of breastfeeding, social mobilization and monitoring of breastfeeding indicators in Brazil.⁴ The actions have different target groups with the common goal of increasing breastfeeding rates in Brazil.

The World Health Organization⁵ classifies breastfeeding in the following categories: Exclusive breastfeeding: the infant receives only breast milk directly from the breast or extracted, and no other liquid or solid food, with the exception of drops or syrups of vitamins, minerals or medicines; Predominant breastfeeding: in addition to breast milk, the infant receives water or water-based drinks, such as fruit juices and teas; and Breastfeeding: the infant is fed with breast milk independently of consuming other liquids or solid/semisolid food, inclusive of non-human milk.

Breastfeeding is encouraged based on the benefits to the mother-child binomial which goes beyond physical health and interferes in the bonding of mother and child. It is known that breast milk has the nutrients needed for the development of infants up to six months of life, not being necessary to use other solids and liquids. The immunological components protect against infectious and allergic diseases and improvement in cognitive development is cited as a long term benefit, which can be attributed to the large amount of energy provided by human milk that aids the process of nerve myelination. For the puerperal, breastfeeding enhances uterine involution preventing postpartum bleeding, it helps the faster return to pre-pregnancy weight and promotes a feeling of relaxation caused by the hormones involved in the process.^5,6 Studies on breastfeeding and public policies describe the biological process and remark the importance of health professionals to encourage and guide patients to make joining the practice to be positive thing, but only a few studies comment on the motivations and disincentives for maternal adherence or non-adherence to breastfeeding. During assistance professionals are sometimes faced with situations of mothers not willing to breastfeed, but these professionals carry on transmitting their knowledge without investigating the reasons for this behavior. Anxiety, tension, pain, stress and uncertainty may inhibit the milk ejection reflex, hence the importance of a dialogue with patients and their families.^5,7

Breastfeeding is transmitted to women as pleasurable practice that is beneficial for them and their babies, however unpleasant sensations are felt, especially in the beginning, until the body adapts and lactation is established on demand. It is common for nursing mothers to feel cramps in the first days postpartum during breastfeeding and this occurs by the action of oxytocin. Other sensations such as breast pain and needle-like feelings when the milk goes down are also described.⁶ Starting from this reflection it was established a guiding question: Why does exclusive breastfeeding up to the sixth month of life have low rates of adherence in Brazil? Given the above, the purpose of the study was to investigate and describe the motivations and disincentives which influence on adherence to exclusive breastfeeding until infant's age of six months.

METHODOLOGY

It is descriptive qualitative exploratory study. It was conducted in Eldorado do Sul / RS, in the Pediatric emergency care (EC) of the municipality. The study included mothers of children who were EC patients aged 18 years and over, mothers of a single fetus, with term delivery (having occurred between 37 and 42 weeks of gestation), fetal birth weight of 2500 grams or more, newborn without complications that required hospitalization in the neonatal unit and infants aged between six and 18 months. Mothers with diseases that contraindicated breastfeeding and mothers who had prematurely weaned the child for medical recommendation were excluded.

Interviews were carried out by the researcher in the Emergency care department between October and December 2009 when mothers sought care for their children. A semi-structured script with open questions was used, together with intentional selection of information found in medical records in the EC, until identifying data saturation (repetitive information shared with the researcher by the participants). The reports were recorded and transcribed and the tapes will be kept in the possession of the author for five years and deleted thereafter. The invitation to participate in the study was done at the moment of screening, before medical consultation.

The analysis of interviews followed the methodology of content analysis in four stages: pre-analysis, exploration of material, treatment of obtained results and interpretation. This process includes organization of the material to be analyzed, defining records, significant items and categories as well as quantification and categorization of information to verify how often the data appeared in the reports. Whenever possible, the text was illustrated with extracts of the interviews to make descriptions more consistent and approach the reader of the content.

Ethical principles were respected in accordance with guidelines of the Resolution 196/96 of the Conselho Nacional de Saúde (National Health Council).⁸ The Project was approved by the Committee of Ethics in Research of the Universidade do Vale do Rio dos Sinos under protocol n°09/092 and by the city hall of Eldorado do Sul. The mothers who agreed to participate signed a consent form in the waiting room of the EC. The consulted authors were referred to throughout the text and the names of the interviewed mothers were replaced by pseudonyms (components of human milk) in order to approach readers of the subject of the article. It should be noted that the study did not receive any financial aid or grants and there was no conflict of interest.

RESULTS

Relationship of human milk with health and child nutrition: a conviction about the nutritional and immunological properties of breast milk was observed in the reports of mothers from group A. Below are some excerpts from interviews that illustrate the properties of milk: I think it's good to breastfeed because it fortifies feeding and it is a remedy too, isn't it (Água); I chose to breastfeed 'cause they don't get sick, they are healthier (Proteína); This one is healthier than the one that wasn't breastfed. The other was breastfed for only one month [...] even the growth is better. The child develops better (Gordura); I think it's very important, my kids were always breastfed and I've seen kids who were never breastfed and they're very different, it's a non-healthy type of fat [...] the child is fat and bloated from wheatflour but is not healthy (Lactose).

Practicality and economy: reports indicate that nursing mothers consider practical not having to prepare bottles, especially at night, or carrying milk and bottles in the bag when they go out with their children, as well as being economical not to spend money buying milk. The reports below illustrate the practicality and economy aspects in the breastfeeding context of this sample: [...] I love sitting somewhere and nursing the baby, just love it, I think it's the most practical thing for the baby and the mother [...] wherever the baby is at the time he wants it, the milk he likes so much is ready. And for us it is more practical because you are with the baby and whenever he asks, you have the milk ready (Caseína); [...] it's all more practical, there's no need to carry bottles, I want to breastfeed for as long as I have milk (Lactoalbumina); [...] my cousin had breast engorgement and didn't make any effort to breastfeed, had to spend money on milk. Normally these mothers who prefer bottle feeding don't wake up late at night to warm up the milk, and the breast milk is warm and ready for the baby (Lactoglobulina).

Enjoyment and promotion of mother-infant bond: these aspects are focused on the pro-breastfeeding movement promoted by the federal government. It is common to see posters with the phrase ''Those who love breastfeed'' (''Quem ama amamenta'' in Portuguese) and this aspect was also verbalized in interviews with participants of group A as a motivating factor for exclusive breastfeeding. Thus it is observed that the act of breastfeeding is not linked exclusively to the instinct of feeding the child, it transcends instinct, involving feelings. The reports below illustrate this point: [...] and it makes a strong bonding between mother and child (Cálcio); [...] it is love, a lot of love, I like to breastfeed [...] the child feels protected and safe with the mother, breastfeeding is all (Fósforo); It's practical to pick up a bottle and leave somebody looking after him, but I think breastfeeding is also important because of the mother-child bonding [...] the moment belongs only to the two of you, there's no third person, that's when you start to notice the little face of your baby and then, when they grow a little it's more special, they're more playful and the mother who doesn't have this... I find it sad (Sódio).

Below are listed the disincentive categories of breastfeeding mothers from group B who were not on exclusive breastfeeding until six months of the child's life (Group B):

Sudden decrease of milk with no apparent cause: the main discouragement factor to exclusive breastfeeding until six months evidenced in the study. Group B participants verbalized the desire to continue breastfeeding but the obligation to initiate feeding with other types of milk due to the small amount of milk produced and its gradual decrease with no apparent cause until the cessation of lactation. In this context they reported that when starting bottle feeding the baby begun losing interest in nursing. Here are fragments of interviews with the group participants: I nursed for one month and 15 days only and then it dried up. Milk stopped out of nowhere, simply dried up (Potássio); I nursed for one month because my milk dried up. I had to start giving other milk and when I began bottle feeding he started not wanting the breast anymore [...] sometimes I still have a little milk, then I give it to him (Ferro); Breastfeeding is good, but I didn't have enough milk. I wanted to have breastfed but my milk dried up, it was not him who stopped breastfeeding, he was still suckling when the milk stopped, it simply dried up from nothing (Vitamina C).

Working outside the home: throughout history feminist movements demanded women's rights and gender equality. Women won the right to vote, to work outside the home, access to contraception and disassociation of sex for procreation with the domain over their own bodies. In this study one of these aspects has been referred to as discouraging factor for breastfeeding, a practice so feminine that involves a strong symbol of femininity, the breast. The following reports illustrate this category: I only stopped before six months because I worked in Porto Alegre and couldn't go back home for breastfeeding and I didn't know I could freeze my milk (Vitamina D); I went back to work when he was four months, so I had to add another milk but I gave more breast milk than the other because I was breastfeeding at daycare, but it was from there that he began weaning (Imunoglobulina A).

Nipple trauma: reported by many participants from both groups. However, these events were a challenging factor for group A mothers, while for mothers in group B they were a discouragement factor for exclusive breastfeeding. The following reports are from participants of group A and B: [...] I had a big problem, that problem in the breast, not mastitis, she wouldn't latch on. I had cracks and bled, I cried because I could tell she was hungry and I cried 'cause I had milk but didn't have the courage to give it to her, but after I got the hang of it, it was very good [...] I tried to bottle feed, my sister pumped it for me because my breasts were full, then she pumped with the machine and I'd put it in the bottle and give it to her. What happened? She suckled twice, the milk was over and I panicked 'cause I thought if I gave it to her one more time she'd get used to it and wouldn't suckle the breast anymore. Then I stopped and breastfed in pain, went through all I've been taught but I carried on breastfeeding (Linfócitos); [...] three months, any of my daughters was breastfed for three months. My breast was dry, got hard, cracked and it didn't have the nipple shape, you know what I mean? Then she wouldn't latch on and it was painful so I had to give her another milk (Macrófagos); In the first days I had cracks because he nursed all the time, a little crying and I'd offer the breast then it cracked and it was very painful [...] I had to give NAN (formula brand) because I couldn't bear the pain and slowly he started weaning and preferring NAN until my breast dried up (Vitamina C).

DISCUSSION

This section of the article will discuss the categories identified in the content analysis comparing the study findings with the literature. Initially the three categories of motivation evidenced in group A will be discussed and subsequently the three discouragement categories of group B.

The relationship of breastfeeding with decreased morbidity and mortality is explained by the composition of human milk and its different stages, from colostrum to mature milk. Thus breast milk is the only food capable of meeting all physiological peculiarities (nutritional and immunological) of infants up to their sixth month of life.^5,6 The immunological properties of human milk have been widely discussed in the media through campaigns promoting breastfeeding and these arouse the interest of the public and health professionals from the mother-child area and encourage this practice in Brazil. The trajectory of breastfeeding in Brazil shows an increase in breastfeeding duration, while at the same time it shows reduction in infant mortality rates.^1,3,9 Breastfeeding is essential for the survival of poor children in underdeveloped countries where there is constant risk of illness due to the complex combination of poor nutrition, lack of sanitation, frequent infections and lack of nutritious food.^6,7

Multiparous mothers in group A that had children who were breastfed and others who were not, mentioned noticing differences between them. This data is shown in the third story of the category 'Relation of human milk with health and child nutrition'. Among the differences observed by mothers are cognitive development and weight gain. The practicality and economy aspects were identified in the study but are also addressed in campaigns to encourage breastfeeding and deserve even more attention in developing countries due to socio-economic disparities. It should be noted that low-income populations are more exposed to infectious and parasitic diseases due to the already described factors such as inadequate sanitation and lack of access to health services, thus breastfeeding is a protective factor as this is a type of milk naturally protected from microorganisms during preparation.⁵

The bonding between mother and child is not innate and breastfeeding represents an opportunity for this bond to be installed or deepened, so breastfeeding is much more than ensuring the survival of species.¹⁰ Breastfeeding is sometimes referred to as a protective factor of an individual's mental health, and when it occurs properly, it favors an enabling environment for the baby development.¹¹

The last report of the category 'Enjoyment and promotion of mother-infant bond' shows that when breastfeeding is successful women's self-esteem is risen, since it represents exclusive care from mother to child. This sentiment triggers tranquility and a sense of well being, contributing to the establishment and maintenance of lactation. The relationship between the increased sensitivity of mothers in the postpartum period with the attitudes of those around them is decisive for maintaining lactation.^6,11

The neonate has all the senses at birth which will be developed and improved with growth. The neonate vision is clear until about 25 cm of distance and at the time of breastfeeding the baby is this distance away from her mother's face. Thus the baby observes her face besides being closer to maternal smell and warmth, which calms the child and stimulates affection between the binomial.¹²

The supply of milk from the bottle as well as the use of pacifiers favor precocious weaning mainly because of the nipple confusion. It consists in a change of positioning of the baby's tongue during suckling and of the suckling movement itself, caused by anatomical differences between the human nipple and artificial nipples. The nipple confusion prevents proper latch when breastfeeding. In addition to this, bottle suction does not require much effort from the infant when compared to the mother's breast, so it is common for babies to prefer the bottle to the breast. Therefore the decrease of lactation and bottle feeding establish a complex cause and effect relation, since hypogalactia motivates women to initiate milk supply from the bottle and this attitude accelerates hypogalactia until the cessation of lactation.⁷ These situations are illustrated by reports from the first category of group B called 'Sudden decrease of milk without apparent cause'.

The difficulties faced by participants working outside the home include problems to go home or to the day care for breastfeeding, and lack of information about freezing and storing their milk. This context prompts a reflection on the labor policy that provides maternity leave of 120 days for jobs in the private sector and the work of professionals who assist these patients in child care consultations. Does that fault lay in professional training or in the lack of interest in teaching these women about the possibilities of emptying the breast and storing breast milk? Unfortunately these questions cannot be answered in this study. Nipple trauma has been cited as occurring over the first days in both groups. Some mothers reported having sought help from health professionals, others reported having sought help from family and friends and others said they did not seek any kind of help. The main problem informed by lactating mothers was nipple cracks and the main product used by them for healing was an ointment recommended by the doctor. Only a few participants reported not having had any problems during breastfeeding showing that it requires perseverance, patience and a lot of desire, as these women reported a lot of pain and suffering, which were challenging factors for group A and discouraging factors for group B.

One of the reports mentions a problem with the breastfeeding technique, which is known to favor the development of nipple trauma, as well as inappropriate emptying of the breast, that implies other problems such as mastitis, engorgement and improper feeding of the neonate. The reports highlight the plight of these mothers who have made efforts and tried to overcome the problems, but felt the need to supplement breastfeeding with other types of milk. The third report of the discouraging category - called 'Nipple trauma' - points to the previously discussed issue on the slighter effort made by babies when sucking the bottle, which favors their preference for artificial milk and the bottle. This same report is also related to the cause and effect relation of hypogalactia and bottle feeding supply. When milk is offered from the bottle the baby begins to prefer it and the number of feedings at the breast is decreased, favoring hypogalactia and cessation of lactation.

Final considerations The story of breastfeeding in the national scenario shows that this practice has passed for moments of disapproval and years later began a pro-breastfeeding movement that lasts until nowadays. Researches over the last decades have brought advances in the knowledge of milk nutritional values, in breastfeeding techniques and in the work of professionals for promoting this practice.

After discussing the findings of this study it can be considered that the decision to exclusively breastfeed involves a number of factors. It is a pleasurable activity for the woman, which favours mother-infant bonding, is healthier and provides better nutrition for children, as well as being practical and economic for mothers. One can still grasp that the women on exclusive breastfeeding until babie's six months have passed through the same nipple trauma that women from the group of non exclusive breastfeeding. Therefore, it is understood, that the decision to keep breastfeeding depends on the interpretation and the will of the nursing mother to overcome these challenges, but not only this factor, also requiring support from their families and health professionals. It is believed that the poor adherence to breastfeeding demonstrated in Brazil is related to social inequalities and labor policies that do not ensure a six month maternity leave nationwide, causing a rift between mother and baby. In addition, poor adherence may be related to lack of support from health professionals to correct and teach the proper positioning of the baby, how to empty the breast and store breast milk so nursing mothers can leave it with caregivers to feed the baby in their absence.

The findings of this study may provide support for a better performance of nurses regarding the problems that make it difficult to continue with exclusive breastfeeding until six months of a child's life, as there are motivating and demotivating factors, as described by nursing mothers. It is recommended that further studies be conducted on the role of health professionals, especially nurses, when assisting nursing mothers going through difficulties to continue with exclusive breastfeeding. Some previously presented statements elucidate the search of mothers for professional help to solve their problems with breastfeeding. However, information from this study is insufficient to determine who are the professionals more involved in this practice and what kind of attitude they have showed.

REFERENCES

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