Breastfeeding self-effi cacy among blind mothers

Objective: To evaluate breastfeeding self-effi cacy among blind mothers. Method: This is a descriptive and exploratory research carried out in Fortaleza-Ceara, with ten blind mothers. Data were collected through an interview with the application of a socioeconomic and obstetric questionnaire and the Breastfeeding Self-Effi cacy Scale – Short Form. Results: The majority of blind mothers presented high breastfeeding self-effi cacy, but there were also mothers with low breastfeeding self-effi cacy. Conclusion: It is necessary to follow-up mothers throughout the entire breastfeeding period to maintain or improve breastfeeding self-effi cacy in this specifi c public. Descriptors: Breast Feeding; Self Effi cacy; Visually Impaired Persons; Maternal-Child Nursing; Weaning. RESUMO Objetivo: Avaliar a autoefi cácia em amamentar entre mães cegas. Método: Trata-se de uma pesquisa descritiva e exploratória, realizada em Fortaleza-Ceará, com dez mães cegas. Os dados foram coletados por meio de uma entrevista com a aplicação de questionário socioeconômico e obstétrico e escala Breastfeeding Self – Effi cacy Scale – Short Form. Resultados: A maioria das mães cegas apresentou elevada autoefi cácia em amamentar, mas também foram evidenciadas mães com baixa autoefi cácia em amamentar. Conclusão: Percebe-se a necessidade do acompanhamento das mães durante todo o período da amamentação para buscar manutenção e melhora da autoefi cácia em amamentar nesse público específi co. Descritores: Aleitamento Materno; Autoefi cácia; Pessoas com Defi ciência Visual; Enfermagem Materno-Infantil; Desmame. RESUMEN Objetivo: Evaluar la autoefi cacia de madres ciegas en la lactancia. Método: Se trata de una investigación descriptiva y exploratoria realizada en Fortaleza, Ceará, entre diez madres ciegas. Los datos se recogieron mediante entrevistas con la aplicación de un cuestionario socioeconómico y obstétrico y con la versión reducida de la Escala de Autoefi cacia para la Lactancia Materna Breastfeeding Self – Effi cacy Scale – Short Form. Resultados: La mayoría de las madres ciegas presentaba una autoefi cacia elevada en la lactancia, aunque también había algunas con autoefi cacia baja. Conclusión: Es evidente que existe una necesidad de seguimiento durante todo el período de amamantamiento para mejorar y mantener la autoefi cacia de la lactancia en este público especifi co. Descriptores: Lactancia Materna; Autoefi cacia; Personas con Defi ciencia Visual; Enfermería Materno-Infantil; Desmame. Anne Fayma Lopes Chaves E-mail: annefayma@yahoo.com.br CORRESPONDING AUTHOR


INTRODUÇÃO
Breastfeeding (BF) is considered one of the fundamental pillars for the promotion and protection of the health of children around the world.The superiority of human milk as food source, protection against diseases and source of affection makes world organizations recommend exclusive breastfeeding for six months of the baby's life and complemented breastfeeding until the second year of life (1) .
In spite of these benefits, the rate of exclusive breastfeeding (EBF) is only 41% in Brazil.Among the Brazilian regions, the Northeast, with only 37%, is the one with the lowest prevalence of EBF in children under six months of age (2) .
Several factors interfere with the breastfeeding process.Among these, the use of pacifiers and supplements (3) , age less than 25 years old (4) , level of education (4) , low family income (4) , low support from health professionals (5) and breastfeeding selfefficacy (6) .Self-efficacy is highlighted as one of the fundamental concepts and principles of health promotion and is defined as the woman's confidence in her knowledge and skills to successfully breastfeed her child (7) .Thus, women need to believe that they can have healthy behaviors so that they can make the efforts necessary to achieve them (8) .
For blind mothers, breastfeeding can be a challenge, since simple acts such as bathing, feeding and administering medication become complex, generating stress and insecurity in their child's care (5) .
According to the Ministry of Health, the health professional must identify and understand BF in the social, cultural and family context and, from this understanding, take care of the mother/child.It is necessary to find ways to interact with the family, seeking to provide effective, solidary, comprehensive and contextualized assistance, respecting the knowledge and life history of each woman, and helping her overcome fears, difficulties and insecurities (1) .
There are currently about 314 million people with visual impairments around the world, of whom 45 million are blind (9) .Besides being a significant part of the population, people with visual impairment face several difficulties to exercise their rights in all aspects of life, including health.Some gaps may be highlighted, such as the need for educational material for people with visual impairment, and the development of assistive technologies that facilitate health education (10) .
In general, blind parents experience difficulties that are similar to those of sighted parents, but with the addition of insecurity to provide care while deprived of vision and precariousness of the social support network in properly guiding them (11) .
Considering the gaps in the literature on BF among blind mothers and knowing the importance of the nursing professional in the care of women in the pregnancy-puerperal cycle, this research will support health professionals, allowing them to know the area in which blind mothers have less confidence, and thus enabling the implementation of strategies for the care and promotion of BF for this public.

OBJECTIVE
To evaluate breastfeeding self-efficacy among blind mothers.

METHOD Ethical aspects
Ethical aspects of research involving human beings established by Resolution 466/12 of the Ministry of Health were respected and the study was approved by the Research Ethics Committee of the Federal University of Ceara-COMEPE.
Design, setting and period of study This is a descriptive and exploratory research, with quantitative approach, carried out between April and June 2017, in the city of Fortaleza -Ceara.

Population or sample: inclusion and exclusion criteria
The study population consisted of blind mothers.Ten women were interviewed because the sample was a rare population.The criterion adopted for inclusion in the research was breastfeeding.Women with mental or cognitive impairments that prevented them from responding to the instruments were excluded from the study.

Study protocol
A non-probabilistic convenience sample was used because the participants were intentionally selected through the snowball technique, in which one participant indicated another and so on.This type of technique is used when it is difficult to find subjects that fit the study.
Data collection was initiated through prior telephone contact with blind women, using the records of a previous research involving this public.The women were invited to participate in the research, and the benefits and purpose of the research were explained.After the acceptance, a face-to-face meeting was held at the participants' home.
The semi-structured interview occurred with the application of a form containing socio-economic data and obstetric history and the Breastfeeding Self -Efficacy Scale -Short Form (BSES-SF).The BSES-SF is a self-administered instrument that seeks to measure mothers' self-efficacy in their ability to breastfeed.This scale is composed of 14 items with answers varying from one (1) (totally disagree) to five (totally agree), and women's total scores range from 14 to 70 points.
This scale was developed by a nurse in Canada and translated into several countries, among them Brazil (12) .It has also been applied in specific populations and this study is the first to apply it in blind mothers.Even though it is self-administered, the health professional can also apply it, which was the method used in this research.

Analysis of results and statistics
Statistical analysis was performed in the Epi Info program version 3.5.3.The exploratory analysis of the data consisted of absolute and relative frequencies, means and standard deviations.The self-efficacy of women was classified as follows: low self-efficacy (14 to 32 points); medium self-efficacy (33 to 51 points) and high self-efficacy (52 to 70 points).

RESULTS
The sample consisted of ten blind mothers aged 22 to 43 years old, with a mean age of 35 years old.Seven women had congenital blindness and three had acquired blindness.Among the participants, six were married, three were single and one was divorced.Five of the participants were housewives, four were students and one was a domestic secretary.
As for parity, five women were primiparous and five were multiparous.When questioned about previous breastfeeding practice six mothers had not performed it and four had had this experience.All the women performed prenatal care.
The majority of the blind mothers presented high self-efficacy in breastfeeding (seven), with scores between 52 and 70 points.Medium self-efficacy was observed in one mother, with scores ranging from 33 to 51 points and low self-efficacy in two blind mothers, with scores ranging from 14 to 32 points.The items that had higher and lower self-efficacy in breastfeeding are presented in Table 1.
To facilitate the understanding of the analysis of the items, the answers were grouped as follows: "totally disagree" and "disagree" were grouped in "disagree" and "totally agree" and "agree" were grouped in "agree".
The highest-scoring item among women for "agree" was "Deal with the fact that breastfeeding can be time-consuming."However, the lowest score of "disagree" was: "Breastfeed my baby without using formula as a supplement".

DISCUSSION
Married mothers or those in a stable union predominated, an aspect that favor increased breastfeeding self-efficacy (13) .Regarding occupation, female housewives prevailed.In the context of breastfeeding, this is considered a protective factor, given that return to work is the main cause of early weaning (14)(15) .
Regarding parity, there was no difference between the mothers' interviews, as shown in a recent study that evaluated the factors related to breastfeeding self-efficacy among teenagers in the immediate postpartum period.There was no statistically significant association between previous obstetric variables (number of pregnancies, parturitions, abortions and live births) and breastfeeding self-efficacy (16) .
A positive finding in this study was that all the participants had prenatal consultations.This fact has great relevance, since recent research involving national and international studies demonstrated that the decision to breastfeed is, in most cases, prior to childbirth (17) .Many women report that they have weaned their children for lack of information.Therefore, it is essential to carry out activities to raise awareness and break down taboos (18) .
Prenatal care is a fundamental moment to advise mothers about the practice of breastfeeding, since it is a period of close contact between mothers and health professionals, who can guide mothers and encourage them to breastfeed.Nursing professionals stand out as the greatest supporters of this practice (19) .
In the present study, a predominance of mothers with high breastfeeding self-efficacy was observed, corroborating a study performed in different regions of Brazil with different audiences (20)(21) .In the context of blind mothers, this finding is considered excellent, since studies indicate that mothers with visual impairment may present greater difficulties to care for their children (5) .
This finding provides benefits to the practice of breastfeeding, since women with high breastfeeding self-efficacy are more likely to breastfeed for at least six months, so this is a contributing factor for the maintenance of breastfeeding (22) .It is believed that raising awareness among professionals and using educational technologies are factors that favor the mothers' knowledge about BF, making them more confident to breastfeed (23) .The importance of the nursing professional must be highlighted, since this professional is responsible for assisting women during the pregnancy-puerperal cycle.
A negative and unprecedented finding of this study was the presence of mothers with low breastfeeding self-efficacy, as no research evaluating maternal self-efficacy had presented this result (20)(21) .Another factor that may have contributed to this low self-efficacy was primiparity, an aspect that is already evidenced in the literature as a risk factor for low breastfeeding self-efficacy (7) .
It is necessary to improve and implement the use of assistive technologies to favor the development of functional ability and enable the performance of the function in which the person is limited due to the disability, thus providing autonomy, quality of life and social inclusion (10) .Regarding the scale, there was great adherence to the item "Deal with the fact that breastfeeding can be time-consuming".This finding may be associated with the fact that the majority of the women interviewed were housewives.These findings disagree with a research evaluating self-efficacy in teenage mothers, which found greatest adherence in the items: "Ensure that my baby is properly latched on for the whole feeding" and "Tell when my baby is finished breastfeeding" (24) .
Corroborating with the findings of another study that applied the BSES-SF to sighted mothers, the item with lower adherence among blind mothers was "Breastfeed my baby without using formula as a supplement" (8) .This demonstrates how EBF is still a complex challenge for health professionals, who need to intervene in several factors that lead to early weaning (25)(26) .

Limitations of the study
The study had as limitation the reduced number of the sample due to the specific public, which made it not possible to carry out statistical tests to associate the variables with the outcomes.
Contributions to the area of nursing, health or public policies The present research brought new knowledge related to breastfeeding among a specific public.Interventions related to breastfeeding should be implemented for blind mothers in order to promote breastfeeding, bringing benefits to the mother/child.

CONCLUSION
Based on the application of the breastfeeding self-efficacy scale it was possible to perceive that blind mothers presented high breastfeeding self-efficacy, a satisfactory finding for the practice of BF.However, there were also mothers with low breastfeeding self-efficacy, a finding not seen in previous studies on this topic.
Knowing that breastfeeding self-efficacy is a changeable aspect, it is necessary to follow up these mothers during the entire period of breastfeeding, so that mothers with high self-efficacy can maintain these levels and mothers with low self-efficacy can improve breastfeeding rates and promote breastfeeding.

Table 1 -
Distribution of BSES-SF items according to the responses of the blind mothers