COMPARAÇÃO DA AUTOEFICÁCIA NA AMAMENTAÇÃO ENTRE PUÉRPERAS ADOLESCENTES E ADULTAS EM UMA MATERNIDADE DE RIBEIRÃO PRETO, BRASIL

Objetivo: verificar e comparar a autoeficacia na amamentacao entre puerperas adolescentes e adultas no pos-parto imediato. 
Metodo: estudo observacional, transversal e comparativo, realizado no alojamento conjunto em uma maternidade, no municipio de 
Ribeirao Preto, Sao Paulo. A coleta de dados foi realizada de janeiro a julho de 2014. Participaram do estudo 306 puerperas adultas e 94 
puerperas adolescentes. Para avaliar a autoeficacia na amamentacao, foi utilizada a versao brasileira da Breastfeeding Self-Efficacy Scale. 
O teste t de Student foi usado para comparar os valores de autoeficacia entre os grupos participantes. Foi considerado um nivel de 
significância de 5% (p=0,05). 
Resultados: entre os dois grupos, a maioria (54%) apresentou autoeficacia elevada, e a diferenca entre os escores nao foi estatisticamente 
significativa (p=0,3482). 
Conclusao: os profissionais devem estar atentos a autoeficacia na amamentacao, direcionando acoes especificas aos grupos de mulheres 
adolescentes e adultas, favorecendo assim o aumento dos indices de aleitamento.


INTRODUCTION
The World Health Organization 1 (WHO) recommends exclusive breastfeeding for infants up to the sixth month of life and complementary breastfeeding until two years or older.] Scientific evidence demonstrates that early weaning is a complex phenomenon, which goes beyond biological determinism and is influenced by psychological, social and cultural factors, being characterized by the introduction of other foods into the diet of children under exclusive breastfeeding up to the age of six months. 6The mothers are aware of the benefits of breast milk, but it is observed that this knowledge is not sufficient to maintain breastfeeding over a long period, as recommended. 7he factors that can influence the duration of breastfeeding include maternal age.
][10][11] Some authors appoint, however, that the association between personal factors and the condition of being an adolescent and having an intimate partner increases the risk of early weaning for the adolescents in comparison with the adult mothers. 12] Therefore, maternal trust has been identified as an variable that influences the start and maintenance of breastfeeding. 19ifferently from the variables that are not or hardly modifiable (such as marital status, educational level and socioeconomic conditions), maternal trust can be modified and lies within the health professionals' access.Its analysis permits identifying the women at greater risk for early weaning and making individual interventions when necessary. 202] Nevertheless, the trust to breastfeed among adolescent mothers has been hardly explored, although some studies have iden-tified that the young maternal age is one of the characteristics of the women who wean early. 18,23he woman's trust in her ability to breastfeed, or the self-efficacy in breastfeeding, is explained by the Theory of Self-Efficacy in Breastfeeding, developed by Dennis 24 based on the construct of trust or self-efficacy, which is part of Bandura's Cognitive Social Theory.25 The self-efficacy construct refers to a factor that mediates the health behaviors, as individuals need to be convinced that they are able to successfully perform a given task or behavior, believing that they will achieve the expected health outcome.Hence, it should be understood that it is not enough for the individual to believe that a certain behavior can help him to achieve a specific objective.He needs to feel able to personally execute that behavior.25 The choice to breastfeed is based on the expected result, which is influenced by four processes: a) if the mother decided to breastfeed or not; b) how much effort is made; c) is she will have self-encouraging or self-destructive patterns of thinking; and d) how she will emotionally respond to the breastfeeding difficulties.The expected self-efficacy, which also interferes in the choice of the breastfeeding behavior, is developed based on the four information sources: a) personal experience; b) vicarious experiences; c) verbal persuasion; and d) psychological and affective condition.24,26 To assess the level of self-efficacy in breastfeeding, Dennis and Faux 27 developed and validated the Breastfeeding Self-efficacy Scale (BSES), a Likert scale whose content was elaborated based on the problems related to the practice and duration of breastfeeding presented in the literature, and has been adapted to different countries, including Brazil.28 Evidence shows that the BSES is a valid and reliable tool that can be used to help health professionals working for breastfeeding, helping to identify women at greater risk of early weaning, as well as the area in which the woman experiences more difficulty.19,26 Studies using the BSES prove that women with higher self-efficacy levels breastfeed longer when compared to women with a higher level of confidence.26,29 Nevertheless, no studies were found that compared the self-efficacy between adolescent and adult women.Hence, the objective in this study was to assess and compare maternal self-efficacy in breastfeeding skills between these two groups. Ths study is intended to help health professionals working with mothers and infants and can contribute to implement actions that favor higher breastfeeding rates.

METHOD
An observational, cross-sectional and comparative study was undertaken of breastfeeding self-efficacy among adolescent and adult postpartum women, developed at the rooming-in unit of a public maternity in Ribeirão Preto, State of São Paulo.The study sample was calculated based on the information from the Annual Nursing Report at the maternity where the study took place, and an earlier study 28 involving the maternal confidence to breastfeed among Brazilian women.It was based on the comparison of means between two groups: adolescent postpartum women and adult postpartum women.Considering a tolerable sampling error of 5%, a 95% confidence level and an expected 10% loss, the sample consisted of 400 postpartum women, being 94 adolescents and 306 adults.
These postpartum women were selected by simple random sampling, through a draw at the rooming-in unit among the women who complied with the following inclusion criteria: postpartum women at least 24h after birth, literate, able to breastfeed, without visual, auditory and/or cognitive impairment, without pathologies or problems after birth, at the rooming-in unit with their infants, born with a gestational age >37 weeks, without special care needs such as phototherapy.
The data were collected between January and July 2014, the period considered to reach the calculated sample.The data were collected from Monday to Friday, in the afternoon, when few care routines happened at the rooming-in unit.Two master's students and one scientific initiation student collected the data through a structured interview, using a questionnaire and information collected from the participants' files.A pilot study was undertaken before the start of the data collection to adapt the best period to contact the postpartum women and the best approach.Two instruments were used to collect the data.The first was developed specifically for this study and considered the identification data and the sociodemographic characteristics, such as age, self-referred color, education, religion, occupation, marital status, type of housing, monthly income and type of help during postpartum (mother, mother--in-law, husband, others); and obstetric characteristics of participants, such as parity, pregnancy planning, prenatal care, date and type of delivery, sex and weight of infant at birth, breastfeeding in the first hour of life and type of feeding at the time of the data collection.The second instrument was the BSES, used to assessed the participants' self-efficacy in breastfeeding skills.
The BSES is a Likert scale with 33 questions, divided in two domains: Technical and Intrapersonal Thinking.Each question comes with five alternative answers, with scores ranging from 1 to 5, being 1-I totally disagree; 2-I disagree; 3-I sometimes agree; 4-I agree; 5-I totally agree.Hence, the total scale scores range between 33 and 165 points. 28Self-efficacy in breastfeeding, identified through the scale, is distributed according to the scores obtained by adding up each question: low self-efficacy (33 to 118 points), medium self-efficacy (119 to 137 points), high self-efficacy (138 to 165 points). 30This instrument has been tested in different phases of the pregnancy-postpartum cycle, and results support its use in any phase of the perinatal period. 31Being a self-applied instrument, the postpartum woman directly answered the BSES without interference by the researchers.Hence, the women answered if and how intensely they agreed or disagreed from each question.
The data were stored in a structured electronic worksheet through double data entry, which permitted the validation of the data, so as to eliminate possible errors and guarantee the reliability in the compilation of the data.To analyze the data, the statistical software Statistical Analysis System SAS ® 9.0 and R version 3.0 were used.
To characterize the sample, the data analysis was based on descriptive statistics.
To compare the self-efficacy in breastfeeding between the study groups, the BSES scores were added up and the mean scores were calculated for the global instruments, for the domains (Technical and Intrapersonal Thinking) and for each postpartum group (adolescents and adults).The mean scores were submitted to Student's t-test.To use the test, it should be tested whether the variances between the two groups are statistically equal and whether the distribution of the data is normal.For this procedure, the PROC TTEST procedure was used in the software SAS ® 9.0.For all tests, significance was set at 5% (α=0.05).Results with p<0.05 and a 95% confidence interval were considered statistically significant.
Approval for the study was obtained from the Research Ethics Committee at the Universidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, protocol 21346013.80000.5393.

RESULTS
Four hundred postpartum women were part of this study, being 94 adolescents and 306 adults.
As regards the adolescent women's sociodemographic characteristics, the participants were characterized with a mean age of 16.53 years (SD=1.44),50% self-declared mulatto, 58% indicated finished primary education, 46% declared having a fixed partner and 52% mentioned living at their own home.Most participants (87%) declared having no paid job and gaining a mean monthly income of 2.23 minimum wages.Concerning the obstetric characteristics, most adolescents (93%) were pregnant for the first time and 65% indicated not having planned the pregnancy.As regards prenatal care, 60% started the monitoring in the first trimester of pregnancy, the majority (85%) having participated in six or more consultations.86% had a normal birth, 57% breastfed during the first hour of life and 92% were in exclusive breastfeeding at the time of the data collection.
Among the 306 adult participants, the mean age was 26.49 years (SD=5.02).Among them, 42% self-declared mulatto, 48% concluded secondary education, 50% had a fixed partner and 41% lived in their own home.Most adult participants (59%) indicated no paid job and the mean income was 2.68 minimum wages.Concerning the obstetric data, 40% of the adults had multiple pregnancies, 35% having given birth multiple times and 76% indicated at least one abortion, 51% did not plan the pregnancy and the majority started prenatal care while still in the first trimester of pregnancy (71%), having six or more consultations during the pregnancy (87%).As regards the type of birth, 70% had normal birth.Fifty-nine percent breastfed in the first hour of life and the majority (91%) were in exclusive breastfeeding at the time of the data collection.
What self-efficacy in breastfeeding is concerned, in the total sample, 54% presented high self-efficacy.Table 1 shows the distribution of adolescents and adults in terms of self-efficacy.Table 2 shows the mean global scores between adolescents and adults and the comparison of means.No statistically significant difference (p=0.3482) was observed between the mean global scores of the adolescent and adult group, that is, between the groups studied, the self-efficacy level in breastfeeding was similar.This result has been illustrated in Figure 1 by the Boxplot distribution.

Adolescent
In the analysis of the Technical domain, the results of the comparison of means showed no statistically significant difference between the groups studied, as can be observed in Table 3.The p-value in the comparison of means showed p=0.2142.This result demonstrated that, concerning the Technical domain of breastfeeding, the level of self-efficacy between the groups was similar.As regards the Intrapersonal Thinking domain, the comparison of means showed no statistically significant difference either, with p=0.7139, that is, the level of self-efficacy for Intrapersonal Thinking aspects is similar between adolescents and adults.Table 4 displays the data for this analysis.

DISCUSSION
In this study, the data were collected 24h after birth, with a view to discovering the self-efficacy level at the start of breastfeeding.Most participants (54.50%) presented a high self-efficacy level.
Among the adolescent postpartum women, the mean BSES score was 138.86, indicating high self-efficacy; among the adults, the mean score was 137.7, indicating moderate self-efficacy, but very close to the bottom limit of high self-efficacy.The results support other studies 26,30 that identified a moderate self-efficacy among adult participants.What the adolescents' result is concerned, no studies were found that analyzed the levels of maternal self-efficacy in breastfeeding in this population using the BSES.In a study in Canada, however, involving adolescent mothers and applying the short version of the BSES, it was demonstrated that, among the adolescents who started breastfeeding, 57% presented high self-efficacy in prenatal care. 32n independent studies developed in China during pregnancy and during the hospitalization among adult postpartum women, low self-efficacy [33][34] was found, differently from the Brazilian reality.
In the analysis of each BSES domain, what the Technical domain is concerned, the mean score was 83.32 among the adolescents and 81.83 among the adults; for the Intrapersonal Thinking domain, the mean score of the adolescents was 55.54 and of the adults 55.55.These results also differ from a study 33 in which a mean score of 63.94 was found for Intrapersonal Thinking and 52.74 for the Technical domain.Pregnant women with lower self-efficacy concerning breastfeeding techniques, having sufficient milk production and family support were observed in a study that concluded that the low self-efficacy levels among them may be due to the limited orientation about breastfeeding received in prenatal care and the inappropriate preparation for breastfeeding. 34he higher self-efficacy levels found in this study can be justified by the fact that the maternity hospital studied is accredited by the Baby-Friendly Hospital Initiative (BFHI).6] The influence of the actions practiced at the BFHI maternity hospital on the breastfeeding self-efficacy levels should be further investigated.In addition, it is important to highlight that, in Brazil, beyond the BFHI, other public policies and programs in favor of breastfeeding play an impor-tant role in the encouragement of breastfeeding, and these governmental strategies have triggered the breastfeeding rates in Brazil; nevertheless, the rates remain inferior to the recommendations. 2,4][39] Identifying the self-efficacy levels in the immediate postpartum and the postpartum women at greater risk for early weaning and who need greater support is an important strategy for health professionals, as women with difficulties to start and establish breastfeeding present low levels of self-efficacy and are particularly vulnerable to interrupting breastfeeding in the first 72h after birth. 40he comparison of the self-efficacy results between adult and adolescent postpartum women presented no statistically significant difference between these two groups, which appoints that maternal age as an isolated variable did not influence the level of maternal self-efficacy in breastfeeding in the immediate postpartum.A study developed in Australia found no association either between maternal age and the level of self-efficacy in breastfeeding. 29In a study developed in Canada, 26 it was observed that the maternal age interfered in the levels of self-efficacy in breastfeeding when associated with the educational level and parity, concluding that older women with a higher education level and more children presented higher self-efficacy scores.In another study developed in China, however, it was demonstrated that, the older the mother, the lower the level of breastfeeding self-efficacy, showing an inverse association between maternal age and the level of self-efficacy. 33Despite these findings, it is highlighted that these studies only involved adult women and that no other study was found in which the results were compared between adolescent and adult mothers.In one study, whose sample included adolescent mothers as from 16 years of age, the mean BSES score was 146.6 points, indicating a high self-efficacy level; 41 in that study, however, the adolescents and adults were not analyzed separately, nor was the influence of (adolescent or adult) age on the scores.

CONCLUSION
Breastfeeding is of fundamental important for maternal-child health and for society.The moment of birth and the hospital practices in the immediate postpartum interfere directly in the construction of maternal self-efficacy in breastfeeding skills.
The is a pioneer study in the analysis and comparison of breastfeeding self-efficacy between adolescent and adult postpartum women.Independently of the age, the women in these groups did not present significant different with regard to the study variable.The participation of postpartum women admitted to a maternity hospital accredited by the IHAC can be considered a study limitation, as these institutions act strongly in favor of breastfeeding, which may have influenced the participants' answers.
Besides this study, few studies were found in the scientific literature that analyzed self-efficacy in breastfeeding in the immediate postpartum.In addition, although the IHAC is a strategy that can strengthen maternal self-efficacy, no studies were found that related the actions or indicators of the Baby-Friendly Institutions with self-efficacy in breastfeeding.Hence, also considering that the BSES can be used at any time in the perinatal period, further research is suggested, so that the women can be monitored prospective and retrospectively, with a view to expanding the knowledge and monitoring of mother and infant with regard to breastfeeding.
As an implication for professional practice, it is highlighted that the assessment of self-efficacy in breastfeeding is an important variable and can be used to identify the women with low levels, facilitating the practice of strategies that contribute to increase the breastfeeding rates.

Figure 1 -
Figure 1 -Distribution of mean total scores on Breastfeeding Self-efficacy Scale between adolescent and adult postpartum women.Ribeirão Preto-SP, 2014