Which factors influence women in the decision to breastfeed?

¿Cuáles son los factores que influencian en las mujeres la decisión de amamantar?

Quais os fatores que influenciam as mulheres na decisão de amamentar?

Cândida Canicali Primo¹;Bruna de Oliveira Nunes²;Eliane de Fátima Almeida Lima ³;Franciele Marabotti Costa Leite⁴;Monica Barros de Pontes⁵;Marcos Antônio Gomes Brandão⁶

¹RN, Ph.D. candidate. Universidade Federal do Espírito Santo - UFES, Vitória, Espírito Santo, Brazil. email: candidaprimo@gmail.com.

²RN, Specialist. UFES, Vitória, Espírito Santo, Brazil. email: bruna_onunes@hotmail.com.

³RN, Ph.D. UFES, Vitória, Espírito Santo, Brazil. email:elianelima66@gmail.com.

⁴RN, Ph.D. candidate. UFES, Vitória, Espírito Santo, Brazil. email:francielemarabotti@gmail.com.

⁵RN, Ph.D. candidate. UFES, Vitória, Espírito Santo, Brazil. email:monicabpontes@gmail.com.

⁶RN, Ph.D. Universidade Federal do Rio de Janeiro - UFRJ, Rio de Janeiro, Rio de Janeiro, Brazil. email: marcosantoniogbrandao@gmail.com.

Receipt date: November 28, 2014. Approval date:September 1, 2015.

Conflicts of interest: none.

ABSTRACT

Objective.Identify the factors that influence women in the decision to breastfeed. Methods. Integrative review. Information was gathered from original articles, case studies, theoretical studies, consensus and systematic reviews published between 2007-2013 in Spanish, Portuguese and English and recovered in the databases MEDLINE and LILACS. The descriptors used in this study were: breastfeeding, maternal behavior, risk factors, lactation and newborn. Results. Were included 30 articles, grouped into five categories. Factors influencing the decision of the breastfeeding woman are a convergence of breastfeeding's advantages, benefits and justifications, family, social and professional support, sociodemographic and clinical characteristics of women, personal experience and family tradition and personal choice. Conclusion. The decision to breastfeed by women is influenced by a convergence of factors. It is essential the role of nursing to encourage women in the decision to initiate and maintain breastfeeding her child.

Key words: breastfeeding; maternal behavior; risk factors; lactation; newborn.

RESUMEN

Objetivo.Identificar los factores que influencian en las mujeres la decisión de amamantar. Métodos. Revisión integrativa.  La información se recolectó a partir  de artículos originales, estudios de casos, estudios teóricos, consensos y revisiones sistemáticas e integrativas, publicados entre 2007-2013, disponibles en los idiomas español, portugués e inglés y recuperados en las bases de datos MEDLINE y LILACS. Los descriptores utilizados en la búsqueda fueron: lactancia materna, comportamiento materno, factores de riesgo, lactancia y recién nacido. Resultados. Se incluyeron 30 artículos agrupados en cinco categorías. Los factores que influencian en las mujeres la decisión de amamantar son una convergencia de ventajas, beneficios y justificaciones de la lactancia materna, entre ellos: apoyo familiar, social y profesional; características sociodemográficas y clínicas de las madres; experiencia personal y tradición familiar; y, finalmente, decisión personal. Conclusión. La decisión de amamantar en las mujeres es una convergencia de factores. Por esto, es fundamental el papel de enfermería en fomentar la decisión de la mujer de iniciar y mantener la lactancia materna.

Palabras clave: lactancia materna; comportamiento maternal; factores de riesgo; lactancia; recién nacido.

RESUMO

Objetivo.Identificar os fatores que influenciam as mulheres na decisão de amamentar. Métodos. Revisão integrativa. As informações foram coletadas a partir de artigos originais, estudos de caso, estudos teóricos, consenso e revisões sistemáticas publicadas entre 2007-2013 disponível em espanhol, português e inglês e recuperados nas bases de dados MEDLINE e LILACS. Os descritores usados na busca foram: amamentação, comportamento materno, fatores de risco, lactação e recém-nascido. Resultados. Foram incluídos 30 artigos agrupados em cinco categorias. Os fatores que influenciam a decisão da mulher de amamentar são uma convergência de vantagens, benefícios e justificativas da amamentação, suporte familiar, social e profissional, características sócio-demográficas e clínicas das mulheres, experiência pessoal e tradição familiar e escolha pessoal. Conclusão. A decisão das mulheres de amamentar é influenciada por uma convergência de fatores. é fundamental o papel da enfermagem em incentivar a decisão da mulher de iniciar e manter a amamentação de seu filho.

Palavras chave:aleitamento materno; comportamento materno; fatores de risco; lactação; recém-nascido.

INTRODUCTION

The World Health Organization recognizes the benefits of breastfeeding and, thus, recommends exclusive breastfeeding for the first six months of the child's life and continued, after the introduction of appropriate complementary foods up to two years or more. The advantages are for the baby, mother and family, considering that, to breastfeed, the mother hugs the child, promoting the desirable bonding in relation mother/child.^1,2 Also, the act of breastfeeding is a function par excellence of the women and constitutes a moment of full realization of femininity, with a strong influence of the social environment and the network of relationships that support the obstacles that women faced during the process of breastfeeding.³ So, it is highlighted the qualitative relevance to research this theme.

Despite the existence of factors that undermine breastfeeding, the act of breastfeeding is intrinsically linked to the mother's role, and as such depends on the character of autonomous women decision making. The breastfeeding phenomenon as focus on nursing diagnosis in NANDA-I is found in caregiver roles of class, recognizing breastfeeding as an element linked to the role of motherhood, extending beyond the nutritional stage.⁴ As a decision, unless in limiting situations, the option whether or not to breastfeed is of the woman. This decision is a process that involves cultural, social and political factors, being influenced by several aspects.^1,5,6

The coverage and complexity of the decision by breastfeeding are linked to the fact that breastfeeding is a process that involves cultural, social and political factors, being influenced by several aspectos.^1,7 However, it is necessary to investigate the factors that influence the decision to breastfeed that may be defined the actions that bring a contribution for a upheld decision, culminating with the preservation of all the breastfeeding benefits.

Knowledge has advanced in relation to aspects of breastfeeding and its influential, especially addressing the physiological, functional aspects or lifestyle habits that modify the effectiveness or continuity of breastfeeding. However, it is unclear how the different aspects can be understood with the research focus a perspective of breastfeeding as decision-making linked to the role of caregiver of women. Thus, this study aims to identify and describe the factors that influence breastfeeding in perspective of a decision-making of a caregiver woman.

METHODOLOGY

This is an integrative review of literature carried out in six stages: (1) identification of the theme and selection of the hypothesis or research question; (2) sampling or literature search with the establishment of criteria for inclusion and exclusion of studies; (3) data collection defining information to be extracted from selected studies and categorization of these studies; (4) critical analysis of the included studies; (5) interpretation and discussion of results and (6) presentation of the review/synthesis of knowledge.⁸

This review has the guiding question: What factors influence a woman's decision-making in breastfeeding? Was held a research through scientific literature, using the search tools of the databases: Latin American and Caribbean Health Sciences (Lilacs) and Medical Literature Analysis and Retrieval Sistem Online (MEDLINE) during the month of January/2014. Were opted for the use of following wide descriptors of Descriptors in Health Sciences (DeCS), in Portuguese, English and Spanish: "Breastfeeding, maternal behavior, risk factors, lactation and newborn". Inclusion criteria were available: original research articles, case reports, theoretical studies, consensus and systematic and integrative reviews. Exclusion criteria: editorials, letters to the editor, monographs, dissertations, abstracts of congress or scientific events.

Considering the big number of articles found using these descriptors, were chosen to work with the crossing of two descriptors for the selection of the studied articles. The search was initially planned to encompass the last five years preceding the year of collection, however, considering the low percentage of articles that supported the guiding question, it was decided to extend two more years of data collection, comprising the years 2007 and 2008. The searches were carried out, independently, by two experienced researchers in review studies.

The first selection of studies was made from the analysis of titles and abstracts, and in cases of doubt about the relevance of the inclusion criteria was also performed to read the full text of publications. In cases of differences between the researchers, the solution came by consensus. Of 3500 selected studies, 3370 articles were excluded from the analysis of the title or abstract. For inclusion, a given article should be compatible with the explicit or implicit perspective of breastfeeding as women's decision-making linked to the role of caregiver. Such analytical framework excluded the contributions of factors related to breastfeeding as act fundamentally nutritional or functional, as well as the productions that take the perspective of the professional, or binomial elements that could not cover the presumed status of women as responsible for the decision making about breastfeeding. Most of the articles included in the review, which passed through the analytical framework of abstracts was obtained in full text format on the website of periodicals of CAPES (Coordination for Improvement of Higher Level or Education Personnel - available in: http://www.periodicos.capes.gov.br ).

Figure 1.

RESULTS

Were found 3   500 articles related to the proposed theme and only 30 had elements that responded to the guiding question and met the inclusion criteria. The highest concentration of publications was in 2009 and 2010 with 6 articles each year; 2008 and 2010 with 5 per year; 4 in 2013; and 2007 and 2012 with 2 articles per year. As for the country of production, 11 studies were conducted in Brazil, 10 in the US, 2 in Hong Kong, 2 in Canada, 2 in Nigeria; 1 in Scotland, 1 in Colombia and 1 in Puerto Rico. As the language was found 18 articles in English, 11 in Portuguese and 1 published in Spanish. Qualitative approach was found 13 studies, cross sectional in 10, cohort in 6 and clinical trial in 1. (Table 1) shows the distribution of articles according with the country, authors, year, language, journal, type of study, sample and main results.

Table 1.

Trough analyze of the results of the selected articles, data were gathered into thematic categories that represents the influencing factors in the decision to breastfeed, as follows: Breastfeeding advantages/benefits/justifications; Family, social and professional support; Sociodemographic and clinical characteristics of the mothers who breastfed; Personal experience and family tradition; and Personal choice.

DISCUSSION

The elements discussed in thematic categories are seen as able to influence in the women decision to breastfeed. The categories presented here are derived from empirical data analysis and are presented in a comprehensive and inductive way. This was done because the studies did not adopt a theoretical framework that take a view of breastfeeding as a responsibility of the caregiver, autonomous and decision maker.

Advantages, benefits, breastfeeding justifications

The benefits of breastfeeding are described in many studies as a factor that influence the woman in the decision make of breasfeed.^1-3,13,18 The knowledge about the advantages of breastfeeding are reported when lactating women point out the importance of breast milk in preventing diarrhea and respiratory infections.³ The meaning of protection of  the breast milk to babies is directly related to its advantages in child growth and development.¹

Among the motivating factors of pregnant women, 73.8% of them decided to breastfeed for the health benefit of child.² These benefits are perceived when mothers say that breast milk protects against diseases, is a vaccine for the baby, helps in weight gain, and in long-term children become less likely to obesity.^1,2,13,18 In addition, Chinese mothers believe that breast milk being removed directly from the breast, does not have contaminants such as mixed feeding, so it's chosen as main food for baby.³¹ The breastfeeding of newborns in special situation was also referred and the justification for mothers breastfeed exclusively their premature children is the possibility to provide a healthy development and good conditions of health for the baby.¹²

Maternal health was mentioned as a benefit of breastfeeding, protecting against breast disease and rapid weight loss cited by mothers are some of advantages.^1-3 The mothers believe that breastfeeding practices are based on the harmony of cyclical and dynamic processes that reinforce physical health, being part of a process of change that reflects and influences the health of the baby and of the mother.³¹

Breastfeeding is seen by mothers as natural process, which provides to the baby all the benefits of a mother's love during this loving interaction and, also a fundamental aspect of their own health.³¹ The link and the establishment of physical contact with the newborn are highlighted by the mother as the most relevant.¹² Still, the economic benefits of breastfeeding appear as a motivator for mothers because they refer that the families spend less money, being economic.^1,17,18

Familiar, social and professional support

For decision making by breastfeeding the women are influenced by the social network that surrounds her, suffering interference, often, in the decision to continue offering exclusive breastfeeding to her son or introduce complementary foods. Similarly, the assessment that the mother do about the child's nutritional status and the ability she has to meet the demands of her son suffers significant influence of the opinion and advice of the closest people and of the health professionals.³

Family influence was defined as knowledge about the opinions and experiences related to infant feeding of people linked by blood or marriage. The family was the most frequently cited factor in breastfeeding decision.¹⁷ The support of relatives is perceived by the mother as essential to successful breastfeeding. Help in daily activities creates a more serene environment, less burdened for women, promoting women's role in her new role, of mother, allowing greater dedication to breastfeeding.¹⁴

The decision of the grandparents was clearly a facilitator and experienced breastfeeding, for generations, within the nurturing family was fundamental to influence mothers about the importance of breast milk for their baby.³ Another figure that influences the decision of how the mother feed her baby is the perception of the father about what is good for the child, because they feel motivated and encouraged by the speech of her partners, being more likely breastfeeding decision when the couple's relationship is good, probably because of the support of the partner in this process and, end up strengthening the marital relationships.^1,14,29 It was verified that the centrality of the decision to breastfeed, most of the time was in the act of breastfeeding or in the variables related to the mother-infant dyad. The prospect of focusing on the decision-making by women decision does not ignore interfering, hindering or facilitating elements exercised by others in other conditions of role, as shown by studies referring to the importance of fathers and grandparents in breastfeeding. However, although related, these are different roles and do not replace the ability of mother's decision-making, which plays the role of main caregiver. The support of friends who experienced a positive breastfeeding and advocate it was one of the major reason for mothers decide to breastfeed, serving as a source of suport.^13,17,18

Regarding the support provided by health professionals, mothers report being oriented, informed and received advice about breastfeeding by nurses of the sector.¹⁸ Information given to the mothers in the postnatal period increase their self-confidence, strengthening her to start and keep breastfeeding and offers security to take care of the baby and herself.⁶ During the prenatal period the women received information about breast massage, breastfeeding until six months of life, proper latch, cracking and skin-to-skin of the mother with the baby after delivery, as advocated by national and international public policy and it is essential to encourage them in this decision.^11,14,18 Also, the participation in support groups favored twice more the women to breastfeed compared with women did not obtain this support.³⁴ The aim of the groups is to inform, answer questions and listen the mothers, addressing topics of interest and doubt among postpartum women as care of the breasts if breast engorgement occurs, bottle feeding use, weak milk and how long to breastfeed.⁶ Teenage mothers who were surrounded by other young mothers reported being comfortable this experience lived with others mothers, said to feel good in this supportive environment and this was considered positive influence for breastfeeding.¹⁸

The relations between breastfeeding support in hospitals and the intention of the woman in practices exclusively breastfeed involves several intrapartum variables, such as use of epidural anesthesia, mode of delivery, length of stay in rooming and location of the baby after delivery. Between primiparas, hospital practices that favored the intention of breastfeeding were: professional help the mother to breastfeed, staff do not do complement to newborn with water or formula, show to mothers community resources to support breastfeeding and staff not giving pacifier. Among the multiparous, significant hospital practices were: encouraging of professionals to breastfeeding and not supplement the babies with formula.³² The study points out that the care provided by nurses includes providing information to women about caring for premature newborns, clarify doubts about her ability to nurture their children and ease their insecurities.¹ Thus, it is extremely important that healthcare professionals who works with breastfeeding in all its aspects in order to show mothers the advantages/benefits and possible difficulties that may be found in the breastfeed of their babies.¹⁴

Sociodemographic and clinical characteristics of mothers who breastfeed

The sociodemographic characteristics of the mother often are related to the decision to breastfeed. American studies show that early breastfeeding rate was higher in white women over the age of 20 years, each additional year of the mother's age corresponded to 1.9% increase in the probability of breastfeeding^25,27,32 and women with health insurance, elevated income, married and nonsmokers were associated positively with intention of breastfeeding.^21,25,32,34 Another issue concerns the religious participation because women attending some religious group, at least once a week, was related to the 55% increase in the chances of start the breastfeeding.²⁸

The level of maternal education is significant in the proportion of mothers who breastfed in the first hour of life of the baby.³⁰ Women who had high school or higher level showed greater intent to breastfeeding.^22,25,32 A higher level of education makes mothers more able to search relevant information about optimal infant nutrition and, more likely to breastfeed their own baby.³³

Women who planned pregnancy and began prenatal care in the first trimester of pregnancy were 25% more likely to opt for breastfeeding.^16,25 And those who had four or more prenatal visits were more favorable to initiate breastfeeding than who did not follow during pregnancy.^23,25 Regarding the number of children or parity, studies still show contradictory results because research in Hong Kong found that parity higher or equal to two children is related positively to practice breastfeeding,²⁶ while American study found that mothers with an older son, the exclusive breastfeeding percentage was higher than in mothers with two or more children, though the association test showed no significant difference between groups (p = 0.76).²⁰ Moreover, data demonstrated that first pregnant mothers were cited as more likely to breastfeed than multiparas.^25,16

In primiparas, intend to breastfeeding was related to prenatal care by obstetrician professional and not cesarean section and in multiparous, was associated with not performing cesarean, the mother have the baby in contact with immediately after birth and residence in rooming for two days or less.³² Another point refers to the gender of the babies, and girls are more likely to be exclusively breastfed than male children.²³ In assessing the type of delivery and complications was observed that women who underwent successful vaginal delivery, after a caesarean section in the first pregnancy are 42% more likely to initiate breastfeeding. Similarly women who attempted vaginal delivery without success, and had cesarean delivery also were more likely to breastfeed than women with repeat programed cesarean.²¹ Also, exclusive breastfeeding rates were higher in women with pregnancy and complicated labor of childbirth and were accompanied in childbirth by health professionals, rather than traditional birth attendants or not prepared people.^23-24 Women who received 13 weeks of maternity leave had a higher rate of early breastfeeding (74.2%) than those who received from one to six weeks. Any time of maternity leave was positively associated with breastfeeding.⁹

Personal experience and familiar tradition

The successful experience of breastfeeding the previous child was a positive precedent in intend to breastfeed a new baby for longer and in an exclusive way.^2,34 The story of a mother about previous child was breastfed and be strong (healthy) confirms the relevance of early onset and reinforces the importance of proper management in the supplementary feed input process, when necessary.⁵

The decision of the woman was heavily influenced by the positive experiences of the family in relation to breastfeeding.^11,18 Memories of breastfeeding experienced by past generations and the proven benefits arise when starts the discussion about issues that are important to the process of breastfeeding, influencing positively its begin.³ Past experiences of family and friends are the so-called influences of cultural values and was found its importance in the breastfeeding process because they potentiated in women the ability to provide to newborns the good development of breastfeeding.¹

Personal choice

The mother's desire is one of the factors for the success of breastfeeding^1,34 and the inner motivation of the mother makes herself to feel safe to breastfeed her children, overcoming obstacles and overcoming barriers that could come to stop early the breastfeeding.³ Also, women who planned to breastfeed exclusively and see this phenomenon as something positive, are more likely to start the breastfeeding.^24,34 The mother's confidence in being able to provide breast milk as the main food source for the baby makes the act of breastfeeding one magic moment.^10,22 And when the woman refers that she wants to breastfeed because of the beauty of breastfeeding, then she seems to be more comfortable with this experience and has more autonomy and freedom to experience the process.² The feeling of pleasure in the breastfeeding is linked to the unconditional love of a mother for the baby, being an act that narrows the bonding between them.¹⁰

The choice of breastfeeding is made independently by the mothers, being a personal choice based often on research in different media or counseling by health professionals.¹⁷ The intention of exclusive breastfeeding was 3.16 times higher among mothers who agree that their babies should be breastfed only with breast milk for the first six months, than in women who had an contrary opinion.¹⁹ Finally, can be concluded that the woman's decision to breastfeed is a complex process that suffers influences of history of woman's life, of experiences of family and friends, demographic, cultural and social factors and also by her desire to breastfeed.

Studies show that mothers have knowledge about the benefits of breast milk for the baby's and her health, and often, is one of the main motivation for the decision to breastfeed. Thus, health education programs in health institutions, educational media campaigns, actions in schools are relevant to spread the advantages/benefits of breastfeeding and broaden the knowledge of society in order to strengthen the breastfeeding promotion message. It was possible to perceive that the women is influenced by the network relations built around her, as members of the family, partner and friends, in this regard, interventions that recognize these influences and involve the people that are significant in teaching about the advantages/benefits of breastfeeding and about the care during the process of breastfeeding can contribute to increase the adhesion of women, the knowledge and support of family and friends.

It is known that breastfeeding is exclusive role of women, but health professionals have an important role in the success or failure of breastfeeding. With regard to health services, hospitals must implement policies that support breastfeeding, with particular attention to the elimination of healthy supplementation of infants and extend professional support during the hospital stay and the first weeks after birth through the home or outpatient care.

The findings of this study are of qualitative nature and results of articles bring convergence that advantage/benefits/ reasons of breastfeeding, the family, social and professional support, the sociodemographic and clinical characteristics of women, personal experience, family tradition and the own choice are the factors that influence the woman in this decision. However these questions cannot substitute the woman's decision-making as an exercise of the role of caregiver that in spite of all seeks to preserve her autonomy, albeit limited, to decide to initiate and maintain breastfeeding her child. It was found that factors such as different cultures or geographical regions can presumably produce different habits and practices and in some way modulate the decision-making of women, because the caring role can change. However, the obtained results didi no show, in world-wide, production that investigate such elements as phenomena of interest, which can be considered as limitation of this review. However, it is noteworthy that the major databases were consulted and, finally, the results point to the need for further studies to better assess the relationship between these factors and the woman's decision to breastfeed.

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