Knowledge, attitudes and practices of grandmothers related to breastfeeding: a meta-synthesis

Objective: Evaluate the knowledge, attitudes and practices of grandmothers that support or discourage the breastfeeding process. Method: This is a meta-synthesis based on the theoretical and methodological framework of meta-ethnography developed by Noblit and Hare. A critical evaluation of the articles was conducted using the consolidated criteria for reporting qualitative research (Coreq). Primary and secondary constructs derived from the results of nine articles were grouped into a new theory, leading to tertiary constructs that were presented in a diagram based on the functionality of Sanicola’s Social Network Theory. Results: Grandmothers know the benefits of breastfeeding, the importance of a special diet and proper hydration for the production of good quality milk, but report inadequacies in the treatment of breast complications and the need for breast milk complementation before the sixth month of life. These aspects were also observed: religious interference, opposition of ideas about breastfeeding, and family decisions based on the grandmother figure. Conclusion: Through knowledge, attitudes and practices, grandmothers, central figures in breastfeeding support, support their daughters and daughters-in-law in breastfeeding or discourage breastfeeding with contrary opinions and inadequate guidance.


Introduction
Breastfeeding is intrinsic to humans; however, it is directly influenced by political, economic, social and cultural aspects, which are passed down to generations. This fact may determine whether the social network will support or discourage breastfeeding, affecting the mother's choices regarding her newborn's feeding (1)(2) .
Among family members, grandmothers are significant figures for transferring information and experiences who influence the mother's breastfeeding decision. In addition, in the postpartum period, grandmothers often spend more time with their daughters and daughters-in-law, providing emotional and financial support, taking care of the mother, the baby and older children, and helping with household chores (3) .
Evidence of grandmother participation in the construction of the breastfeeding process shows that having grandmothers as supporters in maintaining this practice is not always an easy task (3)(4) . According to health professionals, the concepts grandmothers have about breastfeeding and human milk are more difficult to change than those of their own daughters (4) .
Grandmothers have knowledge that has been validated by their experiences, becoming socially accepted, valued and respected, and leading to attitudes and practices that can support or discourage breastfeeding (5) . In this context, such knowledge, attitudes and practices (KAPs) of grandmothers should be analyzed in their different dimensions affecting the process of breastfeeding.
Knowledge can be defined as the understanding of a subject, which results from experience or learning, applied when solving problems or developing concepts. Attitude is linked with the affective domain, whose judgmental tendency is based on feelings, predispositions and beliefs about a given topic. Practice refers to how an action is performed based on one's knowledge and attitudes (6)(7) .

Method
This review is a meta-synthesis, a study method that thoroughly analyzes the theory, methods and results obtained in qualitative studies (8) . This meta-synthesis was built using the theoretical and methodological framework of meta-ethnography developed by Noblit and Hare, which has seven steps: 1) define the area of interest, formulate a study question and develop search strategies; 2) define relevant studies for the study objective; 3) read the studies, recording important information; 4) determine how the studies are related; 5) compare the studies with each other; 6) synthesize the findings; and 7) express the synthesis by presenting the results (9) .
The study aims to answer the following question: "What are the knowledge, attitudes and practices of grandmothers that support and/or discourage the breastfeeding process?" Database search was conducted using Health Sciences Descriptors (DeCS) and their correspondents in the Medical Subject Headings (MeSH) in Portuguese, English and Spanish.
The bibliographic research was conducted in Medline, Scopus, Cuiden, Lilacs, Bdenf databases and SciELO virtual library; three from the health care area, two from multidisciplinary areas, and one from nursing to ensure a broad national and international search. Original articles were included when fulfilling the following criteria: they should be exclusively qualitative studies in Portuguese, English and Spanish investigating knowledge, attitudes and practices of grandmothers related to support or discourage to breastfeeding, and whose participants were mothers and/or grandmothers. An interpretative synthesis of the results, based on the theoretical and methodological framework of meta-ethnography developed by Noblit and Hare (9) , was developed through reciprocal translation of the chronologically organized articles, so that the key concepts identified by thematic analysis of the first article were confronted with the concepts of the subsequent article, feeding the interpretation, and then successively until all articles were analyzed. This step was performed by two independent reviewers and, in the absence of a consensus, two additional reviewers analyzed the item causing disagreement.
The key concepts were allocated to two columns; the first column had concepts from the study participants' understanding (first-order constructs) and the second had concepts from the study authors' interpretation of participants' understanding (secondorder constructs). A synthesis and analysis of primary and secondary constructs originated the third-order or tertiary constructs, which were organized into a new theory resulting from the meta-synthesis (12) .
When analyzing the tertiary constructs, the knowledge, attitudes and practices of grandmothers were favorable or unfavorable to successful breastfeeding.

Results
After searching with the descriptors, 3,693 articles were found; of these, 919 were removed as they were duplicate articles, leading to 2,774 remaining articles.
After applying the inclusion and exclusion criteria and reading the titles, 46 articles were selected for abstract reading; and only then were selected for fulltext reading. However, of these, one article had no full text, despite attempts to acquire it through the Central Library of the Universidade Federal de Pernambuco and contact with the corresponding author.
The reference lists of the articles were analyzed to identify other publications that could answer the study question, but no other study was selected at this stage.
Therefore, nine articles were submitted to a critical evaluation. Figure 1 details the sample selection process.
Data were processed using content analysis (17,19,22,24) , thematic analysis (20)(21)23) and Grounded Theory (18) . One article had no technique description (16) . Regarding the theoretical and methodological framework, the Phenomenological Method (17,23) and the Theory of Culture Care Diversity and Universality (21)(22) were the most frequent ones, followed by the Grounded Theory (18) and the Conceptual Model (24) . Three articles did not describe the theory that guided the study development (16,(19)(20) . Figure 2 shows the characteristics of the studies.
Rev. Latino-Am. Enfermagem 2020;28:e3214.  Figure 1 -PRISMA flow diagram for the selection of articles comprising the study sample (15) Authors, year of publication and country  From the synthesis and analysis of primary and secondary constructs, a Theory was built that shows the type of support offered by grandmothers in the breastfeeding process. Grandmothers are in the central subjects of the diagram, who can support or discourage breastfeeding through their knowledge, attitudes and practices. Figure 3 illustrates the Theory.
The thematic categories linked with the tertiary constructs (knowledge, attitudes and practices) will be represented by the support and/or discouragement grandmothers provide in the context of breastfeeding.
Special diet for the breastfeeding mother; importance of hydrated breastfeeding mother; they promote interaction between mother and child; benefits for child health; benefits for the mother; natural and physiological milk production; breast milk sufficiency to fulfill the child's needs; nutritional information of milk; they identify lactogogues; they know measures to treat complications.
Influence of Islam religion; positive opinion about milk; they value breastfeeding; are an example to be followed.

GRANDMOTHERS DISCOURAGEMENT
Incentive to breastfeeding; help with household chores; provide care to mothers in post-partum period; stick around in the post-partum period; care to older children; transmit information; transmit positive experiences.
PRACTICES Insufficient milk to fulfill the child's needs; complementation with water and other foods is required; influence of mother's diet on milk production; breast care that is proved to be harmful; use of medicinal tea.
Colostrum recognized as poor milk; breastfeeding only until it is comfortable for the mother; conflict between generations; negative opinion about milk; obstacles to grandchild care; eroticized breast; obstacle to work; grandmothers interfere in family decisions.

KNOWLEDGE ATTITUDES
They offer water and other foods before the 6th month of life; feed the child while the mother works out.

Knowledge of grandmothers
Influence of special diet and proper hydration on milk quality Grandmothers identified a specific diet is required, including green vegetables, chicken, meat and nuts, as well as hydration for the maintenance of the mother's well-being and production of good quality milk (16)(17)(21)(22) .
They often attributed special value to some products, lactogogues, which could increase the quality and quantity of breast milk, such as canjica, dark beer and mate (22) . Also regarding the mother's diet and milk quality, grandmothers stated nursing mothers should be cautious about foods that can cause baby colic (19) .
For the mother the following foods are prepared: rice porridge, chicken with condiments, butter, milk, spicy rice, oil and ghee (butter). (GRANDMOTHER) (17) Our food has special ingredients... they say if mothers eat this type of food, their milk will be nutritious. If not, where does the milk come from? (GRANDMOTHER) (17) Rev. Latino-Am. Enfermagem 2020;28:e3214.

Benefits of breast milk
Breast milk was mentioned as a natural and nutritious food (17) , whose production is physiological and sufficient to fulfill the child's needs, making them healthier with reduced allergies, eczema, stomach problems, greater intelligence and stronger bones (16,22,24) . Grandmothers also recognized the immunological properties of milk (21) . Regarding the benefits for the mother, breastfeeding was associated with lower risk of breast cancer, pregnancy prevention and weight loss, also representing a connection between mother and child (16) .  (21) ... it's an act of love. (GRANDMOTHER) (22)

Treating complications (in)adequately
For the treatment of breast engorgement and healing of sore nipples, grandmothers mentioned milk extraction (16) . In other studies, grandmothers emphasized scientifically proven care that are harmful to breasts, such as cleaning at each feeding session, wiping the breasts with alcohol, using ointments to treat cracks, warm compress to treat engorgement, and massage to prevent nipple obstruction (17,22,24) . (GRANDMOTHER) (22) Complementary feeding required According to the grandmothers, children need water before the sixth month of life to quench thirst, moisturize the skin, extend the time between breastfeeding sessions and, when mixed with sugar, treat asthma (16,19) . Complementation with porridge and other foods, in their opinion, should be offered to children who are born crying and hungry, if the mother has little milk or needs to rest and while milk does not come out (16,18,19,21,23) . Teas were frequently used as home remedy to calm a restless child (21) .
[If] a child is born and crying, then we say the child is born hungry, then we give dawale (herb mix) which is water... Then if the baby keeps crying, we also give porridge.
(GRANDMOTHER) (18) Oh, no one can really breastfeed. The milk just doesn't work anymore. I know you are trying, but, you know, you will have no milk. (MOTHER) (19) Oh, something, tea is good, it helps the child calm down.

Religious influence
Islam has a positive influence on breastfeeding as it states milk is Allah's gift to a woman, and if she refuses to offer it to the child, she will have to respond to it. For this reason, Muslim grandmothers encourage breastfeeding for two years or more, unlike Hindus who had no religious references about the time to maintain or discontinue this practice (16) .

Opposed ideas about breastfeeding
Appreciation, positive opinion and approval were also supportive attitudes in the mother's decision to breastfeed (19)(20)(21)(22) . The statements of nursing mothers showed the importance given by them to supporting words, examples to be followed or encouragement from their grandmothers (19) .

My mother used to say: 'this is the best thing you can do,
she really enjoyed breastfeeding her children. (MOTHER) (19) I used to feed my dolls and she [my mother] encouraged me to do it [she said]: 'one day you will grow up, you will be a mother, and you will breastfeed your children (MOTHER) (19) On the other hand, some grandmothers had a India, colostrum is identified as old milk stored in the breast for a long time and that should be discarded (17) .

First, the breast is washed. Khil is washed and thrown
away and then we feed the baby. (GRANDMOTHER) (17) Colostrum is old milk that has been stored in the breast for a long time. (GRANDMOTHER) (16) Another cultural judgment is eroticized breast, leading to shame or disapproval of breastfeeding in public. By associating breasts with pleasure, Malawi's grandmothers believe that couples should refrain from sexual activities in the first year after a child is born, during breastfeeding (18) .
It's because young women don't respect old women, they're busy giving in to their husbands. This is the cause of the problem. (GRANDMOTHER) (18)

Grandmothers as the central figure of family decisions
In different cultures, given the social role of the matriarch, the inherent aspects of child feeding are subjected to the opinion of grandmothers, generating conflicts when their concepts are divergent (18,20,23) .
One study highlighted the opinion of the paternal grandmothers about the most adequate moment to stop breastfeeding and introduce other foods, which was observed by the mothers as they feared their children would be taken away from them (18) .  (23) Believing that they are doing a good thing for their daughters and daughters-in-law, grandmothers recommend breastfeeding should be maintained as long as it is comfortable for mothers and then complemented feeding should be started, so that they can rest or work out, preventing the trauma of a transition between breastfeeding and bottle feeding. In addition, breastfeeding was seen as an obstacle to grandchild care and the creation of a bond between them.

My mother and mother-in-law said: 'It's not good for you
to breastfeed every three hours. You can give the baby some formula. Let me do it so you can sleep.' (MOTHER) (19) ... One disadvantage the mother-in-law saw was that she couldn't stay with the baby when I wasn't there. (MOTHER) (19) Practices of grandmothers

Transmitting information
Grandmothers are responsible for passing on information and experiences in the family, being identified as the first source of advice to be sought.

Grandmothers provided information to their daughters
and daughters-in-law about proper position of the child next to the breast, the need to breastfeed according to the demand, exposure of the breast to sunlight, start of breastfeeding in the first hour of life, and hand cleaning before breastfeeding (16)(17)(18)(19)(20)(21)(22) .

If I have a doubt, the first thing I do is to ask her
[grandmother of the child] if it is good or not. (MOTHER) (21) I feel safe, I feel safer, because she has experience...
(MOTHER) (21) Two sides of support In the post-partum period, grandmothers stayed longer with the nursing mother (21) helping with household chores, providing care to mothers, newborns and older children (18,24) . With the support in the post-partum period and care provided by grandmothers while mothers work out, they give water and other foods to children before the sixth month of life, even though health professionals recommend exclusive breastfeeding.

My mother helped me a lot when I had my children, I want
to do the same thing for my children.
(MOTHER) (20) You can hear at the hospital, but when the child cries, the mother-in-law will ask her to prepare and feed the child with porridge. (MOTHER) (18)

Discussion
The Theory resulting from this meta-synthesis states that the knowledge, attitudes, and practices of grandmothers guide the breastfeeding process of their daughters and daughters-in-law, provide the necessary support for successful breastfeeding and/or promote discouragement seen in early discontinuation.
This Theory was based on studies published in five different continents, with similarities between them and intracontinental particularities due to the existence of distinct ethnic, cultural and religious groups, with emphasis on the type of food that should be eaten by the mother.
The greatest similarity found in the results was an association of a special diet for mothers with milk composition and quality (16)(17)(21)(22)24) . In this context, knowledge promoted support through broad recommendations of grandmothers regarding the foods, beverages, and special products that nursing mothers should eat to produce milk of higher quality and in larger amounts. The foods offered to nursing mothers varied according to local culture, but were unanimous in terms of providing mothers with the best food available.
Although the dietary habits of mothers have little or no effect on most nutrients in human milk (25) , the literature recognizes the existence of artificial or natural substances that support milk production (26)(27) . However, many of the foods mentioned by grandmothers as lactogogues, such as canjica, black beer and mate (21)(22) , have no scientific explanation, but due to the importance of grandmothers, they may ensure mother's self-efficacy and willingness to breastfeed, consequently increasing milk production.
Another aspect in the knowledge of grandmothers that supported breastfeeding was the idea that breast milk is a nutritious food that gives the child strength, health and immunity (21)(22)24) . Regarding the benefits, breastfeeding was related to higher level of intelligence, in agreement with data from a Brazilian study started in 1982 that observed, after 30 years, better performance in intelligence tests in adults who had been breastfed (28) .
In addition, breastfeeding was recognized as an act of love (22) that promotes an affective bond between the Rev. Latino-Am. Enfermagem 2020;28:e3214.
mother and the child, enabling intimacy, exchange of affection and feelings of safety and protection (29) .
In most articles, although grandmothers were positive about breastfeeding for the mother and child (16,22,24) , they recommend the introduction of water and other foods before the sixth month of life (19,21) , as they are unaware that such practices negatively affect the time of exclusive breastfeeding and/or total breastfeeding. Grandmothers believe medicinal tea should be used to calm down or treat any discomfort of the child, such as dehydration and colic (21)(22) .
Only one study reported grandmothers supporting breast milk as a natural, sufficient, necessary and irreplaceable food to fulfill the child's nutritional demands.
For these grandmothers in Nepal, breastfeeding should start shortly after birth and no other foods should be given to the child in the first months (17) .
The opinion of grandmothers about the right moment to give water and other foods to their grandchildren may support and/or discourage breastfeeding, as their knowledge is validated in their own experiences and culturally accepted, influencing decisions about child nutrition (30) .
The opinion of grandmothers about the quality and quantity of breast milk is a crucial point in supporting or discouraging the breastfeeding process. They instinctively tend to fulfill the child's needs so, as long as crying is associated with the idea of hunger due to weak and insufficient milk, they will tend to offer some food which, in their minds, was able to feed other family members who are today strong and healthy, no matter if it is artificial milk, porridge or another food.
Knowledge that discourages breastfeeding also includes inadequate treatment of breast complications when grandmothers mentioned the use of alcohol and warm water (22) , which may harm the skin. Breast problems such as trauma and engorgement are common causes of early discontinuation and, if not properly treated, can be the source of infections and systemic problems requiring hospitalization (31) .
Passing on health information that is not scientifically proven or in disuse is a frequent situation between generations and harmful to a child's health. For health professionals, beliefs, myths and misconceptions about breastfeeding are the result of lack of knowledge about this theme (32) .
Some knowledge that is harmful to breastfeeding is closely related to judgments based on beliefs, such as the representation of breasts as inappropriate and private organs. In contrast, for Muslims, breast milk is a divine gift and should be offered to the child; otherwise mothers will be responsible for their actions before Allah. In Brazil, it is common sense that the puerperal breast is the primary source of food to the detriment of a sexual organ notion (33) .
Attitudes about breastfeeding are influenced by the historical, social and cultural context of each family, showing a mother's decision to breastfeed has an influence of tradition, orientation and encouragement (34) .
Then, maintaining a positive opinion of grandmothers about breastfeeding through appreciation and example in stories or entertaining activities encourage mothers to start or maintain exclusive breastfeeding until the sixth month of life and continuously over the first two years of the child's life.
On the other hand, some grandmothers believe colostrum is old milk that has been stored for a long time in the breast and, therefore, should be discarded, showing poor knowledge about milk composition and relevance (16)(17) . Compared to mature milk, colostrum has a higher amount of protein and less energy, fat and lactose, which are essential for early life (35) . In addition, stimulating a child to maintain skin contact with the mother and breastfeeding in the first hour of life are protective factors for the maintenance of breastfeeding (36) .
Still regarding the attitude of breastfeeding discouragement, for grandmothers who take care of the child while their daughters and daughters-in-law work out, complemented feeding was seen as a tool to avoid the trauma of interrupting exclusive breastfeeding at the moment mothers would return to work. Understanding that going back to work is a risk factor for interrupting exclusive breastfeeding (37) , instructing mothers and grandmothers about breast milk extraction, storing and offering is a safe and inexpensive option.
Opposed ideas about breastfeeding indicate that it is not enough for nursing mothers to have knowledge.
In some places, mothers have little autonomy and the opinion of grandmothers influences family decisions (18) , showing that grandmother education can be as relevant as mother education, which reinforces the importance of family history (38)(39) .

The central role assumed by grandmothers in
the Theory is due to the recognition of their influence on breastfeeding, which will be transmitted through supportive practices. Support is a comprehensive verb, related to counseling, advising, providing information, demonstration, examples, sharing of stories and beliefs (34) .
Family support plays an important role in a woman's decision to breastfeed. Women whose families supported exclusive breastfeeding are 8.21 times more likely to start and continue breastfeeding (40) . In a study with more than 2,000 women conducted in the United States to investigate an association between Angelo BHB, Pontes CM, Sette GCS, Leal LP.
the opinion of family members and health professionals in the success of breastfeeding four weeks after birth, the mothers who believed family members or health professionals preferred breastfeeding were more likely to start breastfeeding (41) .
However, support is provided in a hybrid manner.
While grandmothers transmitted information and performed actions that allowed nursing mothers to have more time for themselves and the newborn (16) by assuming household chores and care for the newborn and older children (18,24) , they, on the other hand, acted as an obstacle to breastfeeding by recommending water, teas and other foods to the child. For this reason, encouraging breastfeeding in the family context should be a priority among nurses and other health professionals.
Recognizing the family habits in the puerperal period helps health professionals plan educational practices consistent with the local culture.
Educational activities are more likely to change paradigms with specific messages for the targeted context, respecting supporters of the belief system: the older members (32) . If grandmothers are well informed about the aspects related to breastfeeding, their knowledge, attitudes and practices will support nursing mothers and directly result in increased breastfeeding rates and a better quality of this experience that involves the mother, child and family.
Despite the systematization used in the search and selection of articles included in this meta-synthesis, it is impossible to cover all studies published about this theme. Another study limitation was the lack of access to full transcription of participant speeches of the primary articles, which could provide a deeper analysis of the studied effect. In addition, the lack of information between the breastfeeding experience and the data collection period may allow recall bias.

Conclusion
In the new Theory produced in this study, maternal to investigate the participation of other significant members in the breastfeeding mother's social network.