New mothers and their understanding about breast milk donation

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Introduction
The act of donating milk gained notoriety with the emergence of the Human Milk Banks (HMB). The first was opened in 1943 in Rio de Janeiro, at the then National Institute of Childcare, now the Instituto Fernandes Figueira (IFF), considered a reference center until nowadays for the others in Brazil. 1 With the development of the National Breastfeeding Incentive Program, especially since 1985, the HMB began to assume a new role in Brazilian public health scenario, becoming strategic elements for actions to promote, to protect and to support breastfeeding. 2,3 The National Network of Human Milk Banks in Brazil (NNHMB) is the largest and best structured network of HMB in the world. It currently has more than 224 HMB and 217 collection points, spread across the country, with the purpose of promoting, protecting and supporting breastfeeding (BF), conducting collection and distributing certified quality human milk (HM), thus contributing to reduce infant mortality. 4 The benefits arising from breast milk (BM) are indisputable, it is considered essential to have HM in volume that makes it possible to attend, in urgent cases, all infants who, due to clinically proven circumstances, cannot breastfeed on occasions for which HMBs are a solution. 5 The donation of HM is a voluntary act, which can be performed by healthy breastfeeding mothers who have excess milk production, in addition to the normal needs of the child. 1 Although there is widespread disclosure in the media and health services about the importance of donation of HM, the number of donations is still low and the HMB reach approximately 60% of the demand for preterm and low weight newborns, hospitalized in neonatal units in Brazil. 6 Given the above, the objective of the present study was to analyze the understanding of postpartum women about the donation of HM and list the factors that motivate or hinder the possibility of becoming donors.

Methods
This is a descriptive-exploratory, quali-quantitative study, with potential mothers of HM donors, in a State Hospital, in the southern region of the State of Tocantins.
During the month of June 2018, an initial approach was carried out to invite participation in the study of pregnant women who performed prenatal care in Basic Health Units (BHU) in the municipality of Gurupi-TO, which has 13 units. The sample consisted of 1 (one) participant per BHU totaling 13 new mothers. In order to guarantee their secrecy and to preserve their identity, fictitious names were given (M1, M2, M3 ...). The pregnant woman was informed about the research and signed the Free and Informed Consent Form (FICF).
This initial link between researcher and participant aimed to make the postpartum approach more harmonious and humanized for both, since the researcher would not be completely unknown to the new mother.
After obtaining the informed consent form, the volunteer or family member made contact with the researcher, by means of a telephone call or text message, when starting labor or in the immediate postpartum period. The researcher immediately after contact went to the hospital and conducted the interview, always after the HMB's visit to the Joint Housing (ALCON). The qualitative approach allows a closer relationship with the world of meanings, of human relationships acquired through experience, making it possible to capture values, motives, operations, beliefs and attitudes. 7 It was essential that the information on the understanding of the mothers was collected in the hospital environment, as the intention of the study was to verify how the understanding about HM donation would be, immediately after the delivery experience and after the visit of the HMB team to the beds, obtaining the understanding of milk donation with which the mothers leave the hospital.
The study included adult mothers, admitted to ALCON, whose children were being breastfed and who agreed to participate in the research. Exclusion criteria were the impossibility of breastfeeding, pregnancy under the age of 19, not accepting to participate in the study or withdrawing consent at any time.
For data collection, a semi-structured questionnaire and interview script were used, in addition to the field diary, to understand the object of the study in its multiple dimensions.
The project was submitted to the Research Ethics Committee of the University of Gurupi (UnirG) and approved according to the opinion: 2,714,637/2018. The socioeconomic, demographic and obstetric antecedents questionnaires were tabulated in the Microsoft Office Excel program and submitted to descriptive analyzes using the Statistical Package for Social Sciences (SPSS) 20.0 software.
For the qualitative analysis, interviews were recorded in audio, faithfully transcribed, on the same day of the collection, added to the descriptions of the observations and to the researcher's impressions, contained in the field diary records. The data were processed using the NVivo Version 11 software to organize data in the qualitative research.
For data analysis, the thematic content analysis technique proposed by Bardin was used, which claims that the term of content analysis is "a set of communication analysis techniques aiming to obtain, by systematic procedures and objectives of content description messages, indicators that allow the inference of knowledge related to the production / reception conditions (inferred variables) of this message ". Consisting of the following stages: preanalysis, material exploration and treatment of results, inference and interpretation. 7

Results and Discussion
The mean age of the interviewees was 24 years-old, with a minimum age of 19 years-old and a maximum of 33 years-old, and an average of 24.62 ± 3.95 years. A study carried out in 2012 in an HMB with SCI donors in Minas Gerais, found that the most frequent age group was between 20 and 29 years-old (48.4%), the majority (96.8%) of them being adults.8 However, although this age group was the most frequent among the donors in the present study, there is evidence that demonstrates that there is no relationship between age and the practice of HM donation. 9 The socioeconomic, demographic and obstetric characteristics of the new mothers are presented in Tables 1 and 2.
The level of maternal education constitutes a positive factor for decision, in relation to the practice of BF and regarding the donation of HM. The higher the level of education, the greater the access to information and, equally, the greater the ease in understanding the information, as well as the greater empowerment about the relevance of BF and donation. 10,11 Maternity pay and leave guarantee that the working woman can stay with her child at the most important moments of her life and thus breastfeed. The binomial needs to be together for several months after birth, when most of the child's brain develops and he is deeply dependent on his mother, emotionally and physiologically. 12 The short duration of maternity leave reported by the participants, or even the absence of it, can make it difficult to breastfeed and contribute to early weaning, influencing the practice of donating milk, due to the lack of the child's sucking stimulus to the mother's breast.
Most of the interviewees 69.2% (9) had already experienced at least one pregnancy, which refers to the reasons that led these women to not have been donors of HM in previous experiences. Research carried out by Alencar and Seidl, 13 with donors from two HMB in the Federal District, shows that most of the women studied were new mothers, indicating that the practice of donation can happen simultaneously to the first experience in breastfeeding.
All mothers performed prenatal care in the public health system and it was observed that the majority of participants (76.9%) performed the minimum number of 6 prenatal consultations recommended, denoting adequate access to health actions and services, during the current pregnancy, by the interviewees.
Regarding the previous practice of breastfeeding, 62.5% (8) performed it. However, only one interviewee (7.7%) had breastfed exclusively until the 6 th month.
When asked how often babies should be breastfed, despite the knowledge shown, the data pointed to the practice of EBF by a small portion of the interviewees ( Table 2).
The World Health Organization (WHO) and the United Nations Children's Fund (Unicef) recommend exclusive breastfeeding (EBF) until the sixth month, as it reduces neonatal and infant morbidity and mortality, in addition to promoting physical, mental and psychic health of the child and the nursing mother. 14 The II Survey on the Prevalence of BF in Brazilian Capitals and the Federal District, carried out in 2009, in relation to BF in the first six months of life, Brazil had a 41% prevalence, in the municipality of Palmas, Tocantins was 35.7%, which is below the national average and WHO's and Unicef's expected goals (60%). 15 Regarding the receipt of guidance in relation to BF, 61.5% of women reported having been advised, 30.8% during hospitalization. Among the professional categories cited as the ones who implement these guidelines, nurses were mentioned 15.4% and doctors 7.7%. Table 3 shows variables that assess the degree of knowledge about milk donation and BF and the intentionality of the mothers regarding the donation. It was observed that the supply of milk in crossbreastfeeding has already been practiced, in previous pregnancies, by 23.1% (3) of the puerperal women Table 1 Socioeconomic and demographic characteristics of women interviewed at the Regional Hospital of Gurupi, Tocantins, and, in all cases, the breastfed children were relatives of the nursing mothers. Likewise, 15.4% (2) of the interviewees have already allowed cross-breastfeeding to their children. The occurrence of cross-breastfeeding still frequently raises concern due to the risks it offers to child's health. Being aware that the risk of a woman carrying the human immunodeficiency virus (HIV) and transmitting the virus through breastfeeding is between 7 and 22% and that this risk is renewed at each feeding, the Ministry of Health contraindicates cross-breastfeeding, as such practice puts the child's health and life at risk, causing an incurable disease that promotes a limited, suffered existence and/or premature death. In addition, other diseases and contaminants of HM (drugs, alcohol, tobacco, sweeteners, caffeine, chemical substances of environmental or occupational exposure, etc.) can also be transmitted. 16 Four of the interviewees (M1, M6, M12, M13) Table 2 Obstetric characteristics of women interviewed at the Regional Hospital of Gurupi, Tocantins, Brazil, 2018 (N=13). reported complications with breastfeeding, requiring the return of the researcher at another time or another day to conduct the interview, in order to collect data at a more suitable time for the mother.

Characteristics N %
Only one of the mothers (M1) among the interviewees had already donated milk. Table 3 Knowledge about breastfeeding, human milk donation and intentionality of donation of mothers interviewed at the Regional Hospital of Gurupi, Tocantins, Brazil, 2018 (N=13).

Categorization
From the reading of the interviews, the Registration Units were elaborated and through them the Elementary Context Units were determined, looking for segments of the testimonies that would help better understanding for coding, as shown in Table  4. The final three categories of analysis were: Understanding about breastfeeding; Health education for improving knowledge and Relation of factors associated with milk donation, and they are shown in Table 5.

Understanding about breastfeeding
Breastfeeding is fundamental to children's health, due to its nutritional, emotional, immunological, socioeconomic and developmental benefits, in addition to maternal health benefits. BF is the ideal feeding practice for infants in the first six months of life, since its advantages are irrefutable, both from a biological and psychosocial point of view. 17,18 When asked about the current experience with breastfeeding, four of the interviewees reported difficulties (M1, M2, M12 and M13) and presented the following statements: Through the speeches, despite the initially negative experiences, the mothers showed optimism and persistence regarding the continuity of breastfeeding, it is inferred that these expressions may be the result of the mothers' understanding of the maternal role during the act of breastfeeding.
A study in which the Unicef evaluation protocol was applied, demonstrated, based on the analysis of 152 binomials admitted under the ALCON regime, that 55% of them had at least one difficulty in the BF. 19 It was observed that mothers use different efforts to offer HM to their child. BF should not be understood as an imposed and obstacle-free activity. Reports of pleasant experiences with breastfeeding were expressed in the excerpts of the following speeches: A qualitative research, carried out with 20 nursing mothers in the city of Rio de Janeiro, reported that BF has different meanings and representations for the female universe, however, all the interviewees converged on a practice aimed essen-Buges NM et al.

Table 5
Final categories of analysis of the interviews with mothers from the Regional Hospital of Gurupi, Tocantins, Brazil,

Elementary Context Units Final Categories of Analysis
BF=breastfeeding; HM= human milk. tially at the child's needs. The survey showed that not every woman enjoyed this practice (15%). Despite being breastfeeding, three women admitted their desire to finish as soon as possible, or stated that they simply did not like to breastfeed. 20 Breastfeeding is an act not perceived in a similar way by all women. Each nursing mother experiences the experience in a peculiar way: for some it is an act of extreme pleasure, happiness and reward; for others, it can be painful and painful. Many women reported feeling breastfeeding as an obligation to be fulfilled and, even in suffering, breastfed. 21

Health education for improving knowledge
When asked how they received guidance on breastfeeding, two interviewees in the present study reported they did not receive any guidance. Family members had their support reported in the interviews, with 30% of the puerperal women reporting that the guidelines on BF came from them. "The things that I know, right? My mother who teaches me, right? But I didn't receive any information like that". Through the speeches, it is observed that the mothers studied here wish to receive information about BF and milk donation through dialogue or lectures, and consider the information provided in the prenatal and puerperium to be relevant. One interviewee mentioned the use of the internet as a means of obtaining information. The health team must take advantage of the impact of the educational process, as it cooperates to bring people together and to strengthen the singular and collective potential, with regard to the valorization of health, the use of available resources and the exercise of citizenship.
Strategies are necessary to facilitate the spread of information about the anatomical, physiological and immunological foundations of breastfeeding; in relation to the clinical management of breastfeeding and breast complications. Health professionals must be able to provide correct information, acting creatively, using the advantages and importance of BF as allies in convincing women to breastfeed, reconciling this practice with other roles practiced by women in society. It is the duty of all health professionals, especially those who work with the pregnancy-puerperal cycle, to act as agents of health promotion, positively influencing the practice of BF. 22

Relation of factors associated with milk donation
As they can be seen in the following speeches, the factors that may make it difficult to donate milk are: lack of knowledge about the donation process; the little time available; and the lack of means of transport and HM collection points. The literature suggests that, in order to alleviate the difficulties encountered by mothers, and to encourage HM donation, lectures with women in the prenatal period are strategic, a moment when you can also invite them to visit the HMB, even during pregnancy, showing them the recipients of donated HM, the processing steps of raw donated HM. 23 Such strategies are feasible to be implemented by the HMBs.
Regarding the factors that encourage donation, altruism was a feeling that appeared in several statements in the present study; as well as the feeling of empathy towards other mothers who, for some reason, were unable to breastfeed. In addition, it was possible to identify that the interviewees understand the importance of HM and its primacy in relation to commercial formulas and other milks. These results are similar to those of a study carried out with donors from an HMB in Cuiabá-MT, which pointed out that the donation was perceived as a solidarity action. It is also relevant to consider that the social context in which the woman is inserted significantly influences her understanding of the dimensions of the donation. In this way, the influence of people close to the nursing mother, such as the spouse; in addition to institutional support, they operate positively towards the predisposition to donate milk. 24 The study leads to the reflection that culture, tradition, values that impose on society during pregnancy can influence breastfeeding.
Still regarding the reasons that would lead to the act of donation, the excess of milk production is mentioned in the speech of M13, and the concern that the donation does not harm the child's own nutrition, mentioned in the speech of M8: A study carried out in an HMB in Tubarão-SC, also listed the excess of milk production, in second place, as a predisposing factor to the attitude of donating, having been mentioned by 22.2% of the donors. 25 A quantitative study, with donors of an HMB, showed that, among the reasons considered most important for donation, was the feeling of benevolence in helping children who need SCI. 26 This feeling of benevolence in helping other children was also evident in this study, as can be seen in the following speeches: The only nursing mother interviewed in this study, who had previously been a donor, says that the current pregnancy transformed her understanding of donation, as her baby needed to receive supplementation, due to low colostrum production, and this fact made her rethink the reasons donation. When she was a donor before, the reason was the excess of milk production. When asked if there was any difficulty with the donation, she reported how difficult the transport problem was to send milk to the HMB, but when she needed the HMB's assistance, she felt welcomed. "The question of access, that's all. The facility only if we 'came' here they serve us well, right?" The interviewees listed as alternatives for attracting new donors: facilitating transport for the sending of milk, carrying out dissemination actions, informing the importance and function of the HMB; and clarification about the destination of the donated milk. They emphasized that they would like to receive information during the prenatal period. maybe they think that milk, many of them that I've seen question that: ah! They will collect my milk and they will not use it, they will throw it away!". (M11)

Field diary
It was observed through the field diary and the interviewees' speeches, that they almost always use the third person of the verbal conjugation, that is, they do not seem to see themselves as possible donors, they just seem to be expressing their opinion about the act of donating. Thus, it is emphasized that the ignorance of the processes that involve the donation of milk by the studied population can make the donation act more difficult, in addition to distancing the volunteer woman from the process, leading her to believe that it is a complex and unlikely practice in reality.
The results of this study can help health services to establish new strategies for attracting potential donors. The HMB, as a public institution that aims to stimulate and to promote breastfeeding, should use health education to improve the understanding of pregnant women about the process involved in the donation of milk, attracting new potential donors and, thus, fulfill their objectives of collecting and distributing HM, meeting the needs of its receivers. Although breastfeeding is considered instinctive and natural, women need to be taught and supported during pregnancy and puerperium, since breastfeeding failure directly influences the practice of HM donation.
The puerperal women showed feelings of empathy and altruism as motivational factors. The data indicate that the nursing mothers understand the superiority of HM in relation to other milks and the importance of donating it, however there is still a need for further guidance, especially in prenatal care, regarding the function of the HMB, benefits of the donation, form transportation and destination of donated milk, since they are factors that sensitize donation in the mothers' view.
This research suggests the need for future studies, which list support indicators for popular health education actions by the service, guiding the making of more effective pedagogical material for dissemination of HM donation, by health profes-sionals in pre-primary care services for pre-natal and birth.

Final considerations
Although feelings of empathy and altruism have stood out as motivational factors for donation, the misinformation of mothers about milk donation and the functioning and performance of human milk banks makes milk donation a complex and distant act from the reality of potential donors.
However, the participants were receptive to information and support regarding breastfeeding and milk donation, in the approaches by the health service during care received in the pregnancy-puerperal cycle, which points to popular health education as a strategy to be adopted for the service.
In health education actions, the team must include the people around the puerperal woman, identified as key supporters in this study.

Authors' contribution
Buges NM performed data collection and analysis, writing of the article. Klinger KAS carried out the methodological conception and data analysis. Pereira RJ participated in the research conception, data analysis and writing of the article. All authors approved the final version of the article.