Print version ISSN 0021-7557
J. Pediatr. (Rio J.) vol.80 no.5 suppl. Porto Alegre Nov. 2004
Lais Graci dos Santos BuenoI; Keiko Miyasaki TeruyaII
School of Medicine, Centro Universitário Lusíada (UNILUS), Santos,
IIPh.D., Universidade de São Paulo (USP), São Paulo, SP, Brazil
To provide health professionals with information on theory and practice of breastfeeding
SOURCES OF DATA: MEDLINE, Bireme library, Lilacs, relevant Internet websites, scientific journals, technical books, essays, theses, and national and international publications were selected, studied and used to provide information on the topic. The most important sources of data were: a publication by the World Health Organization (WHO 1993) and the authors' experience and clinic practice in the assistance of mothers, children and families.
SUMMARY OF THE FINDINGS: A trained pediatrician plays an important role in the increase of breastfeeding rates and its duration. To improve this performance, in 1993, WHO designed a 40-hour course using an important didactic strategy aimed at health professionals and mothers. The goal was to protect, promote and support maternal nursing. It is a professional way of dealing with the mother by listening and trying to understand her, offering her help on planning, taking decisions, and getting strength on how to deal with pressures, thus increasing her confidence and self-esteem.
CONCLUSION: Scientific evidences prove the effectiveness of Breastfeeding Counseling. Moreover, health professional's knowledge and practice are very important to increase breastfeeding rates.
Key words: Breastfeeding, counseling, breastfeeding counseling, maternal nursing, medical education, pediatrician.
Homo sapiens the most widely adapted species in the animal scale found very early on that there were alternative sources to human milk to feed its offspring.1 This practice has been extensively explored, pushing humans further away from the mammalian condition.2 The price for breaking this paradigm is too high, since breastmilk reduces the risk of infection and infant mortality and increases the mother/baby bonding, which can improve the quality of life in the future, in addition to other advantages.3-15 The improvement of alternative sources to breastmilk explains the decrease in breastfeeding duration and rates on a worldwide basis, especially in the last century.16 In Brazilian capital cities, the average breastfeeding duration is 10 months. However, the average exclusive breastfeeding duration is only 23 days, varying from region to region.17
To reverse this situation, several measures have been proposed and implemented by international organizations such as WHO/UNICEF, the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists,18-20 and also by Brazilian organizations such as the Ministry of Health, Health Institute of São Paulo, State Health Departments,21 Brazilian Society of Pediatrics, among others. These measures include, among others, education in breastfeeding management, training of health professionals and breastfeeding counseling.
With regard to education in breastfeeding management, a PAHO/WHO survey conducted in Brazil in 1994 revealed that medical schools, which deliver approximately 8,345 hours on average, devote only 26 hours (0.13% of the total amount of hours) to breastfeeding management. Since then, there has been some improvement in the amount of hours taught and in the teaching of breastfeeding management, thanks to the efforts of the Brazilian Ministry of Health, with its centers for breastfeeding management, and also to some of the organizations mentioned above.
A pediatrician with expertise in breastfeeding plays a crucial role in promoting the breastfeeding practice, directly influencing its duration and rate.22-27 Pediatricians are trained to detect problems and solve them; to do that, they use the complaints made by the mother as the basis for their clinical judgment; however, they do not always have a picture of the actual problem experienced by the mother. When a mother seeks a pediatrician, she expects to have good assistance and the solution to her problems, but she seldom has an opportunity to expose her feelings and to contextualize her difficulties, maybe due to the inability of the professional to build a bridge between theory and practice. Thus, the meeting between the pediatrician and the mother is not as profitable as it should be. It is often common to come across one of the following situations: mothers who start to breast-feed in a satisfactory manner, but introduce complementary feeding or cease to breast-feed a few weeks after delivery; and pediatricians, with lack of experienced in breastfeeding management, who cannot provide satisfactory assistance.
The further understanding of the problems that surround a medical appointment so as to diagnose them properly and then be able to help a mother to solve her problem is the mainstay of breastfeeding counseling.28 Breastfeeding counseling has been especially recommended since 1994 by the Canadian Task Force on Preventive Health Care (CTFPHC) and by the US Preventive Services Task Force (USPSTF). These recommendations are based on evidence regarding some reviews about the effectiveness of breastfeeding promotion interventions on a worldwide basis. Evidence shows that breastfeeding rates and duration increase when women receive breastfeeding counseling.29-31
Counseling is defined by McKinney et al.32 as "an interpersonal relation in which a counselor helps individuals in their psychological wholeness to more efficiently adjust themselves and to the environment." It is also considered as "helping individuals to make decisions in order to solve their own problems, including objective information that enables a better use of personal resources."33
It is important to notice the difference between simply giving advice and counseling. Giving advice is to tell someone what to do; counseling is concerned with the way pediatricians professionally approach a mother by listening to her, trying to understand her, and then with their knowledge, offer her help to plan and take decisions and be strong enough to deal with pressure, thus increasing her self-confidence and self-esteem.28
Breastfeeding counseling in Brazil
"Breastfeeding Counseling: a Training Course" has been implemented since 1995, and has been supported by the Brazilian Ministry of Health, State Health Departments and Health Institute of São Paulo. The course was an initiative by the Control of Diarrheal Diseases (CDD) conjointly with WHO/UNICEF, which devised and implemented the course, which was first tested in 1991 in the Philippines, in 1992 in Jamaica and in 1993 in Bangladesh. Since then, several countries have implemented this course, whose aim is to train health professionals in some specific skills in order to make communication easier and implement a constructive action, considering the physiological bases of lactation. The course has an overall duration of 40 hours, and provides some strategies for an easier communication between health professionals (counselors) and mothers.28
An assessment of the Breastfeeding Counseling course implemented in Brazil concluded that participants acquire counseling skills, however, in order for them to apply what they have learned, the clinical management of lactation has to be improved and there should be continuous supervision.34
The skills recommended in the WHO/UNICEF Breastfeeding Counseling Management are shown in Table 1.
Practical applications of breastfeeding counseling
Prenatal care with breastfeeding counseling
During pregnancy, women behave differently from usual, having questions, showing insecurity and fear. This makes them more sensitive and more susceptible to pressures from their families, health professionals and friends with regard to their breastfeeding ability. In addition, mothers might be in conflict with themselves about their decision to breastfeed. In this context, mothers may easily lose their confidence and self-esteem and feel very likely to bottle-feed their infants.
Mothers with a solid self-esteem can resist the pressures against breastfeeding. The following recommendations are particularly useful during prenatal care:
Give due attention to the feelings exposed by the mother, respecting her decision about what she finds best for her and her child, not causing worries or doubts about her ability to produce milk.
Leave the final decision to the mother and show that she is able to choose what is best for her and her child; health professionals should only give suggestions and relevant information with scientific evidence in a clear and simple language. A mother always has a practical know-how, so health professionals should share their knowledge about breastfeeding with her.
Perceive the real reason for the medical appoint. Identification of the actual complaint (which is not always reported) is the key to appropriate suggestions on breastfeeding.
Correct wrong ideas and give accurate information in a positive manner, without it sounding like a criticism. By providing information, pediatricians show they have expertise in the topic. However, by talking away about it, their information and suggestions may not be properly understood or might not be accepted by the mother. Therefore, it is important to select only one or two pieces of relevant information to be given in a positive manner and in such a way that the mother can perceive what should be changed, always having a humble attitude towards the mother.
Reinforce the importance of the medical appointment. Such an appointment may have different meanings for the mother: interrupting her routine, exposing her feelings, waiting for assistance, spending money and time. A simple appointment is always very important to a mother who seeks help and/or guidance.
Pay attention to the verbal and nonverbal behavior of the mother and health professional. This is the first step of the appointment, which sometimes develops without any perception about the difference hidden between the lines of communication that involves looking without seeing and hearing without listening. Before speaking or by not speaking at all, health professionals may make communication easier or, on the contrary, cause the mother's interest to wane. Thus, the communication between health professionals and the mother during an appointment may take place without any verbal expression, only by means of body language. Health professionals should show strong conviction, naturalness, and use some body language when giving the mother the following message: "I'm interested in attending to you and listening to whatever you have to tell."
Show care and attention from the moment the mother arrives at the hospital/unit until she leaves. Welcoming the mother, which is the first step in establishing a good doctor-patient relationship, is paramount here.
A strategy used at the Santos Lactation Center (HGA/UNILUS) in prenatal care is group dynamics33 in waiting rooms, involving mothers-to-be and the people who accompany them. The introduction of all participants is important to break the ice and warm up the meeting. All participants should feel included, feeling free to make their questions, learn from other participants' experiences, solve problems and make their decision about breastfeeding. For improved results, the group dynamics coordinator should remind the participants of the relevant information that was not mentioned during the meeting (without exceeding 30 minutes) and explain it to them in simple language.
Delivery room with breastfeeding counseling
It has been recommended that mother and child should not be separated after delivery, unless an acceptable medical reason for that does exist.35 A pediatrician, while assisting the newborn in the delivery room, may come across either of the two situations regarding breastfeeding: a well-prepared mother who received prenatal care and an unprepared one.
In case of unprepared mothers, it is recommendable to have a previous talk with them about the importance of early contact (within the first hour after delivery), that is, skin-to-skin and eye-to-eye contact, which should be established immediately after childbirth. The language used should be simple and straightforward. Technical words may not be understood by the mother. Suggestions should be given rather than orders. Orders lower self-confidence and take the decision-making away from the mother.
If the unprepared mother accepts your suggestion, from then on the same assistance given to prepared mothers should be provided. All-out support and practical help should be provided so that early contact can be established. For instance: helping the mother to hold her baby so that the skin-to-skin contact occurs. Some practical help may provide an open line of communication between the professional and the mother, in addition to arousing a feeling of gratitude in her. If the mother feels comfortable, she will pay attention to the information and suggestions the health professional has to give. On the other hand, when the mother feels uncomfortable, tired, thirsty, or has already received a lot of information, some practical help is better than many words.
It is of paramount importance that the pace established by mother and child for the contact be respected in order to guarantee the success of the subsequent step: infant being induced by the mother to feed spontaneously.
Breastfeeding with counseling in the rooming-in facility
When health professionals smile at the mother, nodding their head, they show that they are there to help and open a positive line of communication that ends up encouraging the breastfeeding practice.
In the immediate puerperium and on the first days after delivery, practical help is the most important skill in breastfeeding counseling. For example: observing the mother's surroundings so that she can relax and rest, in addition to making her feel comfortable (by offering her access to pillows, armchairs, chairs, water, painkillers, etc.).
In the rooming-in facility, empathy is another important skill. It is the key to counseling and also the key to the identification and understanding between individuals; it manages the feelings and does not only discuss them. This process stimulates the mother's self-discovery. Empathy is not a magical process, but it is indeed mysterious. It does not seem easy to understand because it is so common and basic.
Empathy should not be mistaken for sympathy (which means feeling sorry for someone or something) which, instead of making things easier, may block communication by shifting the focus of attention away from the mother. In appointments in which sympathy prevails, pediatricians feel for what is happening to the mother and analyze the situation from their point of view. In case of empathy, they listen to the mother and show her that they have understood her feelings, from her point of view; the focus should be placed on the mother and on her feelings. The mother/health professional relationship is strengthened when empathy is used, the mother is carefully listened to and praised for her correct actions.
Other counseling skills to be developed for better observation and evaluation of breastfeeds include: suggesting instead of ordering the mother to get the infant to feed; observing a whole breastfeed without hurry; and interfering only when requested or authorized by the mother.
Follow-up of breastfeeding with counseling
For continuity of breastfeeding, a mother needs to receive support and help that is specific to her difficulties or to her self-confidence problems. In the follow-up, the concern with welcoming the mother is similar to that in prenatal care. Group dynamics before the appointments provides the mothers with relevant information, calming them down and facilitating the communication with the health professional during assistance.
Practical help is also important and includes three different phases: having doorkeepers especially trained to welcome mothers with a smile and a caring attitude, indicating where they should go for assistance; avoiding bureaucratic formalities or a waiting line; accommodating them comfortably while they wait. Another way to offer some practical help is by giving mothers a snack, juice or just water. After group dynamics, mothers have an individual appointment in which they will learn some facilitating attitudes (Table 1).
How questions are formulated also counts. Open-ended questions, in addition to encouraging mothers to talk and expose what they feel, maximize the duration of the appointment. Open-ended questions usually begin with words such as: "how;" "what;" "who;" "where;" etc. Yes/no questions lead to inaccurate information and may block communication. However, they are sometimes necessary. Example: "Did you receive prenatal care?" Specific questions get communication going. Example: "When did you start to breastfeed?" Sometimes, too many questions are asked, resulting in useless answers, thus getting the mother to speak less.
By reporting what the mother has just said health professionals show that they understood what she said. This way, she will probably talk more about the topic and may help take the conversation to a deeper level. Nodding, smiling or using expressions such as "Really?"; "Huh huh!"; "Mmm..."; "Gosh!"; "So?"; "I know" to react are a way to show that health professionals are listening and that she can count on them, and also a way to encourage mothers to talk.
A breastfeeding mother loses self-confidence quite easily and may succumb to the pressure from family members and friends to wean prematurely. It is essential that health professionals make the mother feel confident and comfortable with herself, avoiding the use of some words right, wrong, good, bad, plenty (of), appropriate, by the book, normally, enough, problem since these words may sound judgmental.
All counseling skills should be used during the appointment, with special emphasis on empathy, accepting what the mother says, not judging her, not "imposing" behaviors and attitudes regarding the breastfeeding practice, praising, informing and suggesting so that the mother can decide what is best for her child.
Providing mothers with proper information about breastfeeding is not an easy task at all, but it should be overcome. Health professionals should be always aware and prepared to change their routine and behavior and remember that even if mistakes occur sometimes, the most important is to try and do things right. Changing the paradigm of care based on breastfeeding counseling is still a challenge to be overcome.
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Keiko Miyasaki Teruya
Rua Piauí, 32
CEP 11065-420 Santos, SP
Phone: +55 (13) 3202.1355/3237.3322