Original article • Artículo original • Artigo original Exclusive breastfeeding: motivations and disincentives for mothers in Eldorado do Sul, Brazil

Juliana Machado Schardosim1 Petronila Libana Rauber Cechim2

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

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 to18 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.

1 RN, Master student Universidade de Brasília, Brasília, DF - Brazil. email: [email protected] Lactancia materna exclusiva: motivaciones y 2 RN, Master. Professor UNISINOS, Sao desmotivaciones de las madres lactantes Leopoldo, RS - Brazil. de Eldorado do Sul, Brasil email: [email protected] Resumen Article linked to research: Aleitamento materno exclusivo. Motivações e desmoti- Objetivo. Describir las motivaciones y desmotivaciones que vações das nutrizes de Eldorado do Sul. influencian la adhesión a la lactancia materna exclusiva hasta los seis meses de vida del niño en el municipio de Eldorado do Subventions: none. Sul (Brasil). Metodología. Investigación exploratoria descriptiva cualitativa. Se entrevistaron, de octubre a diciembre de 2009, a 25 Conflicts of interests: none. madres de niños de 6 a 18 meses de vida. Resultados. Emergieron tres categorías de motivaciones: la leche humana y la salud y Receipt date: Oct 30, 2012. nutrición del niño, practicidad y economía, y placer y promoción del vínculo madre-bebé; y tres de desmotivaciones: diminución Approval date: Aug 20, 2013. brusca de la leche sin causa aparente, el trabajo fuera del hogar, y How to cite this article: Schardosim JM, problemas con los senos y los pezones. Conclusión. La decisión de Cechim PLR. Exclusive breastfeeding: amamantar al niño menor de seis meses envuelve un conjunto de motivations and disincentives for nursing factores que debe enfrentar la madre durante la lactancia. mothers in Eldorado do Sul, Brazil. Invest Educ Enferm. 2013;31(3): 377-384. Palabras clave: lactancia materna; enfermeríaInvest Educ obstétrica; Enferm. 2013;31(3) destete. • 377 Juliana Machado Schardosim • Petronila Libana Rauber Cechim

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

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 chave: aleitamento materno; enfermagem obstétrica; desmame.

Introduction

Breastfeeding (BF) is a widely discussed topic in that lead these mothers to abandon breastfeeding nursing. It is a practice with numerous benefits for in order to develop actions aimed at the causes. the mother-child binomial. A successful BF is not dependant only on the willingness and availability The Ministry of Health in its National Policy of the nursing mother; assistance and guidance for the Promotion, Protection and Support of from health professionals is also important, from Breastfeeding has some strategies: rede Amamenta to and recovery, until the Brasil (Breastfeeding network), Brazilian network return of the nursing mother and her baby to the of human milk bank, Baby friendly hospital Basic Health Unit. The prevalence of exclusive initiative, legal protection of breastfeeding, social and non-exclusive BF in Brazil in 1999 was, mobilization and monitoring of breastfeeding respectively, of 53.1% and 88% in the first 30 indicators in Brazil.4 The actions have different days and of 9.7% and 72.9% between 151 and target groups with the common goal of increasing 180 days of the child’s life.1,2 In the South region breastfeeding rates in Brazil. of Brazil the prevalence of exclusive and non- exclusive BF was respectively 64.3% and 82.3% 5 in the first 30 days and 12.9% and 65.2% The World Health Organization classifies between 151 and 180 days.1-2 A study conducted breastfeeding in the following categories: Exclusive by the Ministry of Health of Brazil in 2009 showed breastfeeding: the infant receives only prevalence of exclusive breastfeeding in babies directly from the breast or extracted, and no other under six months of 41% in Brazil, and of 43.5% liquid or solid food, with the exception of drops in the South region of the country.3 It is observed, or syrups of vitamins, minerals or medicines; therefore, that throughout these ten years, even Predominant breastfeeding: in addition to with the creation of programs and public policies breast milk, the infant receives water or water- of attention and encouragement to BF as well as based drinks, such as fruit juices and teas; and incentives in the media, breastfeeding rates have Breastfeeding: the infant is fed with breast milk increased but still remain below 50%. In this independently of consuming other liquids or solid/ scenario it is important to investigate the reasons semisolid food, inclusive of non-human milk.

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Breastfeeding is encouraged based on the the purpose of the study was to investigate and benefits to the mother-child binomial which describe the motivations and disincentives which goes beyond physical health and interferes in influence on adherence to exclusive breastfeeding the bonding of mother and child. It is known until infants’ age of six months. 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 Methodology against infectious and allergic diseases and improvement in cognitive development is cited as It is descriptive qualitative exploratory study. It a long term benefit, which can be attributed to was conducted in Eldorado do Sul / RS, in the the large amount of energy provided by human Pediatric emergency care (EC) of the municipality. milk that aids the process of nerve myelination. The study included mothers of children who were For the puerperal, breastfeeding enhances uterine EC patients aged 18 years and over, mothers of a involution preventing postpartum bleeding, it single fetus, with term delivery (having occurred helps the faster return to pre- weight between 37 and 42 weeks of gestation), fetal birth and promotes a feeling of relaxation caused by weight of 2500 grams or more, newborn without the hormones involved in the process.5,6 Studies complications that required hospitalization in on breastfeeding and public policies describe the the neonatal unit and infants aged between six biological process and remark the importance and 18 months. Mothers with diseases that of health professionals to encourage and guide contraindicated breastfeeding and mothers who patients to make joining the practice to be had prematurely weaned the child for medical positive thing, but only a few studies comment recommendation were excluded. on the motivations and disincentives for maternal adherence or non-adherence to breastfeeding. Interviews were carried out by the researcher During assistance professionals are sometimes in the Emergency care department between faced with situations of mothers not willing to October and December 2009 when mothers breastfeed, but these professionals carry on sought care for their children. A semi-structured transmitting their knowledge without investigating script with open questions was used, together the reasons for this behavior. Anxiety, tension, with intentional selection of information found in pain, stress and uncertainty may inhibit the milk medical records in the EC, until identifying data ejection reflex, hence the importance of a dialogue saturation (repetitive information shared with with patients and their families.5,7 the researcher by the participants). The reports were recorded and transcribed and the tapes will Breastfeeding is transmitted to women as be kept in the possession of the author for five pleasurable practice that is beneficial for them years and deleted thereafter. The invitation to and their babies, however unpleasant sensations participate in the study was done at the moment are felt, especially in the beginning, until the body of screening, before medical consultation. adapts and lactation is established on demand. It is common for nursing mothers to feel cramps The analysis of interviews followed the methodology in the first days postpartum during breastfeeding of content analysis in four stages: pre-analysis, and this occurs by the action of oxytocin. Other exploration of material, treatment of obtained sensations such as breast pain and needle- results and interpretation. This process includes like feelings when the milk goes down are also organization of the material to be analyzed, described.6 Starting from this reflection it was defining records, significant items and categories established a guiding question: Why does exclusive as well as quantification and categorization of breastfeeding up to the sixth month of life have information to verify how often the data appeared low rates of adherence in Brazil? Given the above, in the reports. Whenever possible, the text was

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illustrated with extracts of the interviews to make their children, as well as being economical not descriptions more consistent and approach the to spend money buying milk. The reports below reader of the content. illustrate the practicality and economy aspects in the breastfeeding context of this sample: [...] Ethical principles were respected in accordance I love sitting somewhere and nursing the baby, with guidelines of the Resolution 196/96 of just love it, I think it’s the most practical thing the Conselho Nacional de Saúde (National for the baby and the mother [...] wherever the Health Council).8 The Project was approved baby is at the time he wants it, the milk he likes by the Committee of Ethics in Research of the so much is ready. And for us it is more practical Universidade do Vale do Rio dos Sinos under because you are with the baby and whenever protocol nº09/092 and by the city hall of Eldorado he asks, you have the milk ready (Caseína); do Sul. The mothers who agreed to participate [...] it’s all more practical, there’s no need to signed a consent form in the waiting room of the EC. carry bottles, I want to breastfeed for as long The consulted authors were referred to throughout as I have milk (Lactoalbumina); [...] my cousin the text and the names of the interviewed mothers had breast engorgement and didn’t make any were replaced by pseudonyms (components of effort to breastfeed, had to spend money on human milk) in order to approach readers of the milk. Normally these mothers who prefer bottle subject of the article. It should be noted that the feeding don’t wake up late at night to warm up study did not receive any financial aid or grants the milk, and the breast milk is warm and ready and there was no conflict of interest. for the baby (Lactoglobulina).

Enjoyment and promotion of mother-infant bond: these aspects are focused on the pro-breastfeeding Results movement promoted by the federal government. It is common to see posters with the phrase “Those Relationship of human milk with health and who love breastfeed” (“Quem ama amamenta” in child nutrition: a conviction about the nutritional Portuguese) and this aspect was also verbalized and immunological properties of breast milk was in interviews with participants of group A as a observed in the reports of mothers from group motivating factor for exclusive breastfeeding. Thus A. Below are some excerpts from interviews that it is observed that the act of breastfeeding is not illustrate the properties of milk: I think it’s good to linked exclusively to the instinct of feeding the child, breastfeed because it fortifies feeding and it is a it transcends instinct, involving feelings. The reports remedy too, isn’t it (Água); I chose to breastfeed below illustrate this point: [...] and it makes a strong ‘cause they don’t get sick, they are healthier bonding between mother and child (Cálcio); [...] it (Proteína); This one is healthier than the one is love, a lot of love, I like to breastfeed [...] the that wasn’t breastfed. The other was breastfed child feels protected and safe with the mother, for only one month [...] even the growth is better. breastfeeding is all (Fósforo); It’s practical to pick The child develops better (Gordura); I think it’s up a bottle and leave somebody looking after very important, my kids were always breastfed him, but I think breastfeeding is also important and I’ve seen kids who were never breastfed because of the mother-child bonding [...] the and they’re very different, it’s a non-healthy moment belongs only to the two of you, there’s no type of fat [...] the child is fat and bloated from third person, that’s when you start to notice the wheatflour but is not healthy (Lactose). little face of your baby and then, when they grow a little it’s more special, they’re more playful and the Practicality and economy: reports indicate that mother who doesn’t have this... I find it sad (Sódio). nursing mothers consider practical not having to prepare bottles, especially at night, or carrying Below are listed the disincentive categories of milk and bottles in the bag when they go out with breastfeeding mothers from group B who were not

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on exclusive breastfeeding until six months of the challenging factor for group A mothers, while for child’s life (Group B): mothers in group B they were a discouragement factor for exclusive breastfeeding. The following Sudden decrease of milk with no apparent cause: reports are from participants of group A and B: the main discouragement factor to exclusive [...] I had a big problem, that problem in the breastfeeding until six months evidenced in the breast, not mastitis, she wouldn’t latch on. I had study. Group B participants verbalized the desire cracks and bled, I cried because I could tell she to continue breastfeeding but the obligation was hungry and I cried ‘cause I had milk but to initiate feeding with other types of milk due didn’t have the courage to give it to her, but after to the small amount of milk produced and its I got the hang of it, it was very good [...] I tried to gradual decrease with no apparent cause until the bottle feed, my sister pumped it for me because cessation of lactation. In this context they reported my breasts were full, then she pumped with the that when starting bottle feeding the baby begun machine and I’d put it in the bottle and give it losing interest in nursing. Here are fragments of to her. What happened? She suckled twice, the interviews with the group participants: I nursed milk was over and I panicked ‘cause I thought if for one month and 15 days only and then it dried I gave it to her one more time she’d get used to up. Milk stopped out of nowhere, simply dried it and wouldn’t suckle the breast anymore. Then up (Potássio); I nursed for one month because I stopped and breastfed in pain, went through all my milk dried up. I had to start giving other milk and when I began bottle feeding he started not I’ve been taught but I carried on breastfeeding wanting the breast anymore [...] sometimes I still (Linfócitos); [...] three months, any of my have a little milk, then I give it to him (Ferro); daughters was breastfed for three months. My Breastfeeding is good, but I didn’t have enough breast was dry, got hard, cracked and it didn’t milk. I wanted to have breastfed but my milk dried have the nipple shape, you know what I mean? up, it was not him who stopped breastfeeding, Then she wouldn’t latch on and it was painful so he was still suckling when the milk stopped, it I had to give her another milk (Macrófagos); In simply dried up from nothing (Vitamina C). the first days I had cracks because he nursed all the time, a little crying and I’d offer the breast Working outside the home: throughout history then it cracked and it was very painful [...] I had feminist movements demanded women’s rights to give NAN (formula brand) because I couldn’t and gender equality. Women won the right to vote, bear the pain and slowly he started weaning to work outside the home, access to contraception and preferring NAN until my breast dried up and disassociation of sex for procreation with the (Vitamina C). 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. Discussion The following reports illustrate this category: I only stopped before six months because I worked This section of the article will discuss the categories in Porto Alegre and couldn’t go back home for identified in the content analysis comparing the breastfeeding and I didn’t know I could freeze my study findings with the literature. Initially the milk (Vitamina D); I went back to work when he three categories of motivation evidenced in group was four months, so I had to add another milk but A will be discussed and subsequently the three I gave more breast milk than the other because discouragement categories of group B. I was breastfeeding at daycare, but it was from there that he began weaning (Imunoglobulina A). The relationship of breastfeeding with decreased morbidity and mortality is explained by the Nipple trauma: reported by many participants composition of human milk and its different from both groups. However, these events were a stages, from colostrum to mature milk. Thus

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breast milk is the only food capable of meeting The last report of the category ‘Enjoyment and all physiological peculiarities (nutritional and promotion of mother-infant bond’ shows that immunological) of infants up to their sixth month when breastfeeding is successful women’s self- of life.5,6 The immunological properties of human esteem is risen, since it represents exclusive care milk have been widely discussed in the media from mother to child. This sentiment triggers through campaigns promoting breastfeeding and tranquility and a sense of well being, contributing these arouse the interest of the public and health to the establishment and maintenance of lactation. professionals from the mother-child area and The relationship between the increased sensitivity encourage this practice in Brazil. The trajectory of mothers in the with the of breastfeeding in Brazil shows an increase in attitudes of those around them is decisive for breastfeeding duration, while at the same time maintaining lactation.6,11 it shows reduction in infant mortality rates.1,3,9 Breastfeeding is essential for the survival of poor The neonate has all the senses at birth which children in underdeveloped countries where there will be developed and improved with growth. is constant risk of illness due to the complex The neonate vision is clear until about 25 cm combination of poor nutrition, lack of sanitation, of distance and at the time of breastfeeding the frequent infections and lack of nutritious food.6,7 baby is this distance away from her mother’s face. Thus the baby observes her face besides Multiparous mothers in group A that had children being closer to maternal smell and warmth, which calms the child and stimulates affection between who were breastfed and others who were not, the binomial.12 mentioned noticing differences between them. This data is shown in the third story of the The supply of milk from the bottle as well as the category ‘Relation of human milk with health and use of pacifiers favor precocious weaning mainly child nutrition’. Among the differences observed because of the nipple confusion. It consists in by mothers are cognitive development and weight a change of positioning of the baby’s tongue gain. The practicality and economy aspects were during suckling and of the suckling movement identified in the study but are also addressed itself, caused by anatomical differences between in campaigns to encourage breastfeeding and the human nipple and artificial nipples. The deserve even more attention in developing nipple confusion prevents proper latch when countries due to socio-economic disparities. It breastfeeding. In addition to this, bottle suction should be noted that low-income populations are does not require much effort from the infant more exposed to infectious and parasitic diseases when compared to the mother’s breast, so it is due to the already described factors such as common for babies to prefer the bottle to the inadequate sanitation and lack of access to health breast. Therefore the decrease of lactation and services, thus breastfeeding is a protective factor bottle feeding establish a complex cause and as this is a type of milk naturally protected from effect relation, since hypogalactia motivates microorganisms during preparation.5 women to initiate milk supply from the bottle and this attitude accelerates hypogalactia until The bonding between mother and child is the cessation of lactation.7 These situations are not innate and breastfeeding represents an illustrated by reports from the first category of opportunity for this bond to be installed or group B called ‘Sudden decrease of milk without deepened, so breastfeeding is much more than apparent cause’. ensuring the survival of species.10 Breastfeeding is sometimes referred to as a protective factor of The difficulties faced by participants working an individual’s mental health, and when it occurs outside the home include problems to go home properly, it favors an enabling environment for the or to the day care for breastfeeding, and lack baby development.11 of information about freezing and storing their

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milk. This context prompts a reflection on the passed for moments of disapproval and years later labor policy that provides maternity leave of began a pro-breastfeeding movement that lasts 120 days for jobs in the private sector and the until nowadays. Researches over the last decades work of professionals who assist these patients have brought advances in the knowledge of milk in consultations. Does that fault lay nutritional values, in breastfeeding techniques in professional training or in the lack of interest and in the work of professionals for promoting this in teaching these women about the possibilities practice. of emptying the breast and storing breast milk? Unfortunately these questions cannot be answered After discussing the findings of this study it can in this study. Nipple trauma has been cited as be considered that the decision to exclusively occurring over the first days in both groups. Some breastfeed involves a number of factors. It is a mothers reported having sought help from health pleasurable activity for the woman, which favours professionals, others reported having sought help mother-infant bonding, is healthier and provides from family and friends and others said they did better nutrition for children, as well as being not seek any kind of help. The main problem practical and economic for mothers. One can still informed by lactating mothers was nipple cracks grasp that the women on exclusive breastfeeding and the main product used by them for healing until babies’ six months have passed through the was an ointment recommended by the doctor. same nipple trauma that women from the group Only a few participants reported not having had of non exclusive breastfeeding. Therefore, it is any problems during breastfeeding showing that understood, that the decision to keep breastfeeding it requires perseverance, patience and a lot of depends on the interpretation and the will of the desire, as these women reported a lot of pain nursing mother to overcome these challenges, and suffering, which were challenging factors for but not only this factor, also requiring support group A and discouraging factors for group B. from their families and health professionals. It is believed that the poor adherence to breastfeeding One of the reports mentions a problem with the demonstrated in Brazil is related to social breastfeeding technique, which is known to favor inequalities and labor policies that do not ensure the development of nipple trauma, as well as a six month maternity leave nationwide, causing inappropriate emptying of the breast, that implies a rift between mother and baby. In addition, poor other problems such as mastitis, engorgement adherence may be related to lack of support from and improper feeding of the neonate. The reports health professionals to correct and teach the highlight the plight of these mothers who have proper positioning of the baby, how to empty the made efforts and tried to overcome the problems, breast and store breast milk so nursing mothers but felt the need to supplement breastfeeding can leave it with caregivers to feed the baby in with other types of milk. The third report of the their absence. discouraging category - called ‘Nipple trauma’ - points to the previously discussed issue on the The findings of this study may provide support slighter effort made by babies when sucking the for a better performance of nurses regarding the bottle, which favors their preference for artificial problems that make it difficult to continue with milk and the bottle. This same report is also related exclusive breastfeeding until six months of a child’s to the cause and effect relation of hypogalactia life, as there are motivating and demotivating and bottle feeding supply. When milk is offered factors, as described by nursing mothers. It is from the bottle the baby begins to prefer it and recommended that further studies be conducted the number of feedings at the breast is decreased, on the role of health professionals, especially favoring hypogalactia and cessation of lactation. nurses, when assisting nursing mothers going through difficulties to continue with exclusive Final considerations. The story of breastfeeding in breastfeeding. Some previously presented the national scenario shows that this practice has statements elucidate the search of mothers for

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professional help to solve their problems with 5. Ramos CV; Almeida JAG; Alberto NSMC; Teles breastfeeding. However, information from this JBM; Saldiva SRDM. Diagnóstico da situação do study is insufficient to determine who are the aleitamento materno no Estado do Piauí, Brasil. professionals more involved in this practice and Cad Saúde Pública. 2008; 24(8):1753-62. what kind of attitude they have showed. 6. Tamez RN, Silva MJP. Enfermagem na UTI Neonatal. 3rd ed. Rio de Janeiro (RJ): Guanabara Koogan; 2006. 7. Chaves RG, Lamounier JÁ, César CC. Fatores References associados com a duração do aleitamento materno. J Pediatr Materno. 2007; 3(3):241-6. 1. Ministério da Saúde (BR), DATASUS. Taxa de Prevalência de Aleitamento Materno Exclusivo 8. Ministério da Saúde; Conselho Nacional [Internet]. Brasília; 1999 [cited 2010 feb 15]. de Saúde. Resolução Nº 196/96 – Normas Available from: http://tabnet.datasus.gov.br/cgi/ regulamentadoras de pesquisa envolvendo seres idb2007/d20.htm humanos. Brasília (Brasil): Ministério da Saúde; 1996. 2. Ministério da Saúde (BR), DATASUS. Taxa de Prevalência de Aleitamento Materno [Internet]. 9. Ministério da Saúde (BR), DATASUS. Taxa de Mortalidade Infantil [Internet]. Brasília; 2007 Brasília; 1999 [cited 2010 feb 15]. Available [cited 2010 feb 15]. Available from: http://tabnet. from: http://tabnet.datasus.gov.br/cgi/idb2007/ datasus.gov.br/cgi/idb2008/c01b.htm d19.htm. 10. Beche N, Halpern R, Stein AT. Prevalência do 3. Ministério da Saúde, Brasil. II Pesquisa de aleitamento em um município serrano do Rio Grande Prevalência de Aleitamento Materno nas Capitais do Sul, Brasil. Revista Amrigs. 2009; 53(4):345-53. Brasileiras e Distrito Federal. 1st Ed. Brasília (DF): Editora do Ministério da Saúde; 2009. 11. Carvalho CM, Bica OSC, Moura GMSS. Consultoria em Aleitamento Materno no Hospital de Clínicas 4. Promoção Proteção e Apoio ao Aleitamento de Porto Alegre. Revista HCPA. 2007; 27(2):53-6. Materno [Web site]. Brasília: Ministério da Saúde (BR); 2011 [cited 2010 Jan 11]. Available from: 12. Klaus MH, Klaus PH. Seu surpreendente recém- http://portal.saude.gov.br/portal/saude/cidadao/ nascido. Veronese MAV, translator. Porto Alegre visualizar_texto.cfm?idtxt=26350 (RS): Artmed; 2007. 111p.

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