versión impresa ISSN 0080-6234
Rev. esc. enferm. USP vol.44 no.3 São Paulo sept. 2010
Sentimentos de mães ao amamentarem seus bebês prematuros em sistema de alojamento conjunto
Sentimientos de madres al amamantar a sus bebés prematuros en sistema de alojamiento conjunto
Rejane Marie Barbosa DavimI; Bertha Cruz EndersII; Richardson Augusto Rosendo da SilvaIII
IObstetric Nurse. PhD in Health Sciences. Professor of the Nursing Department, Federal University of Rio Grande de Norte. Natal, RN, Brazil. email@example.com
IINurse. PhD in Nursing at Texas Woman's University. Denton, Texas, USA. Professor of the Nursing Department of Federal University of Rio Grande de Norte. Vice-Coordinator of the Master's Program of the Nursing Department of Federal University of Rio Grande de Norte. Natal, RN, Brazil. firstname.lastname@example.org
IIINurse. Master's Degree in Health Sciences. Doctoral student in Health Sciences at Federal University of Rio Grande do Norte. Natal, RN, Brazil. email@example.com
This study aimed at learning about the feelings experienced by mothers while breastfeeding their premature babies in a rooming-in facility, by means of individual interviews with 33 mothers during the period of February to April 2006, at a maternity hospital in Natal/RN/Brazil. The main feelings referred by the mothers regarding their inability to breastfeed their premature babies immediately after delivery were: sorrow, guilt, disappointment, frustration, insecurity, and fear of touching, holding or harming the delicate babies while breastfeeding. However, the mother-child bond that was formed when the baby was discharged from the Neonatal Intensive Care Unit and taken to the rooming-in facility was reflected by feelings of fulfillment, pride, and satisfaction at experiencing the first breastfeeding.
Key words: Infant, premature. Breast feeding. Mothers. Rooming-in care. Emotions. Mother-child relations.
Estudo teve o objetivo de conhecer os sentimentos de mães ao amamentarem seus bebês prematuros em Sistema de Alojamento Conjunto. Entrevistas individuais foram realizadas com 33 mães acompanhantes no período de fevereiro a abril de 2006, em uma maternidade-escola de Natal/RN/Brasil. Os principais sentimentos referidos por essas mães resultaram em tristeza, culpa, decepção, frustração, insegurança, medo de tocar, segurar ou até mesmo de prejudicar seus delicados bebês quando amamentados. Porém, o vínculo formado entre mães e bebês quando os mesmos recebem alta da Unidade de Terapia Intensiva Neonatal para o Sistema de Alojamento Conjunto se reflete nos sentimentos de realização e orgulho, os quais são marcados pela satisfação da primeira mamada.
Descritores: Prematuro. Aleitamento materno. Mães. Alojamento conjunto. Emoções. Relações mãe-filho.
Estudio realizado con el objetivo de conocer los sentimientos de madres al amamantar a sus bebés prematuros en Sistema de Alojamiento Conjunto, realizándose entrevistas individuales con 33 madres acompañantes en el período comprendido entre febrero y abril de 2006, en una maternidad escuela de Natal / RN / Brasil. Los principales sentimientos referidos por esas madres resultaron en tristeza, culpa, decepción, frustración, inseguridad, miedo de tocar, asegurar o hasta incluso de perjudicar a sus delicados bebés mientras eran amamantados. No obstante eso, el vínculo creado por madres y bebés cuando los mismos reciben el alta de la Unidad de Terapia Intensiva Neonatal para el Sistema de Alojamiento Conjunto, se manifiesta en los sentimientos de realización y orgullo, los cuales son determinados por la satisfacción de la primera lactancia.
Descriptores: Prematuro. Lactancia materna. Madres. Alojamiento conjunto. Emociones. Relaciones madre-hijo.
The birth of a premature baby is a distressing event in a woman's life. Therefore, it is important that the mother's need for support be recognized by the family and care providers, so that she can overcome the difficulties resulting from the child's health condition. Some authors(1-2) support this notion of emotional stress when they point out that a premature birth brings about a crisis that generates feelings of frustration, sorrow, fear and guilt in its members, requiring time for them to accept and adapt to the situation.
A qualitative study conducted with 20 mothers of babies between 31 and 36 weeks gestational age showed that these women experienced feeling of sadness, fear, guilt, trust, and hope at breastfeeding(3). Similarly, in a sectional qualitative study with 8 mothers of premature infants treated at a public health clinic of the Unified Health System in Brazil, the investigators observed that even though the mothers viewed the act of breastfeeding as a gratifying experience, they also expressed feelings of guilt, frustration, incompetence, fear, and anxiety(4). Others report on the effect that support groups have on the emotional stress that families experience upon the birth of a premature infant(5); corroborating the presence of fear and anxiety.
These studies seem to indicate that when the family is faced with a sudden premature birth, the joyful expectation of a healthy baby is transformed into a situation of anguish and uncertainty at the baby's health risk associated with its anatomic and physiologic immaturity. With the advent of the premature and fragile baby, the natural rhythm which surrounds the birth of the child is altered and changes in the family routine occur mostly when the family has to deal with the baby's extended hospitalization in the Neonatal Intensive Care Unit (NICU). The long hospitalization period at the NICU hinders the mother-infant bonding that, in turn, enhances the mother's uncertainty regarding her care of the child(6-7).
The situation is further complicated by the NICU hospitalization, which is described as an additional stress factor by all family members. Besides the risk that the premature baby is naturally exposed to, the family faces other implications related to the intensive care treatment required during the prolonged hospital stay(8-9).
It is known, for example, that while in NICU environment, the baby may undergo procedures and interventions that impact on the parents' suffering. Care procedures such as intubation, aspiration, catheterization, intravenous puncturing, among other invasive interventions, can evoke pain and conflict in the mothers. Feelings of powerlessness also may occur while attempting to control the anxiety and expectations of the treatment(10).
The separation of mother and baby during internment in the NICU, therefore, bring up stress and intense emotions in family members, especially in the mother. It disrupts the family structure that is fundamental to the physical, mental and social development of the baby. Different from the mother that has a term baby, the mother of a premature baby experiences apprehensive moments regarding the effects of the baby's special needs upon the dynamics and emotional stability of the family. In addition, fear of the unknown and of the hospital environment enhances her emotional crisis(6).
It is comprehensible, then, that the stress of having to deal with the physical state of the baby and the instability of family relations during the extended hospitalization may lead to psychological disorders within the family. In order to promote the bonding that needs to be established between mother and baby, and to minimize the negative effects of the separation, most hospitals adopt the rooming-in policy.
In a rooming-in facility, the mother is encouraged to stay overnight in the hospital setting. Being close to the baby encourages the mother's frequent personal contact with the baby, facilitates the opportunity for breastfeeding, and promotes the feeling of knowing what is happening to the infant. It is in this facility that mothers can learn how to contribute to the care of their premature babies while they prepare for discharge. In addition, it offers an opportunity for health professionals to provide support to the mother and family members.
Most hospital institutions in Brazil, therefore, comply with the recommendation of the Ministry of Health to make a rooming-in facility available for these mothers. It is highly important to make the benefits of breastfeeding in rooming-in available to the many premature infants. These benefits have been noted as improved nutritional and immunological properties, maturation of gastrointestinal function, increased neuro-behavioral performance, protection against infections, better cognitive and psychomotor development, minor incidence of re-hospitalization, and increased mother/child bonding(6).
Considering the importance of support when addressing the mother about her premature newborn, it is necessary to give positive information regarding the condition of the baby during the rooming-in experience. This minimizes feelings of anxiety, frustration, and guilt related to breastfeeding doubts and uncertainties that might ultimately make this mother more vulnerable and dependent. It is important, therefore, that the mothers´ feelings during the rooming-in experience be investigated so that maternal care can ensue appropriately.
In considering the need for the study of feelings among mothers in these situations, the premature newborn is understood as a delicate being with physiologic immaturity that is in need of maternal care. Furthermore, it is understood that the provision of adequate care will contribute to the decrease of morbidity and mortality rates in this population, and to the prevention of sequelae(9). In addition, some basic assumptions about breastfeeding are considered: that it is an important component of maternal care needed by all babies, that it is a socially constructed phenomenon and that it must be a pleasurable and guilt-free practice.
Although emotions and feelings can be viewed from a neurobiological perspective, in this study, feelings are understood as expressions of emotions that direct an action. Feelings occur as a result of the interpretation that the individual makes of the event or situation to which he is exposed. Feelings, therefore, become a prompt for the action that ensues. In the case of negative feelings occurring as a result of the baby's hospitalization and his critical state of health, these may interfere with the breastfeeding process(11).
This study is warranted because of the importance of understanding the maternal introjection process and the resultant feelings when breastfeeding premature babies. It is believed to be socially relevant insofar as it contributes to the care plan for mothers that accompany their babies in a rooming-in facility. In addition, the study seeks to contribute to the understanding of the mothers' conflicts when confronted with the need to nurse their babies and the constraints brought about by the health condition of their premature baby.
The present study aimed to learn the mothers' feelings while breastfeeding their premature babies in a rooming-in facility.
This is an exploratory descriptive study with a quantitative approach. An exploratory study allows the investigator to gain experience about a specific problem(12); in this case, the emotional component of the mother during breastfeeding, and it is limited to the description of their feelings. It is quantitative due to the measures and calculations that it uses(13).
The study was conducted at the Januário Cicco University Maternity Hospital (MEJC) of the Federal University of Rio Grande do Norte (UFRN), located in Natal, Rio Grande do Norte, Brazil. The maternity hospital provides obstetrical and neonatal health care and maintains a rooming-in facility and NICU. The hospital has been awarded the Child Friendly Hospital by the Ministry of Health. The title is awarded by the Brazilian Ministry of Health to hospital institutions that have notably directed efforts and actions towards the promotion of breastfeeding amongst mothers.
The subjects were 33 women who had given birth to a premature baby and were, at the time of the study, accompanying their infants in the rooming-in facility. Data were collected during the period from February to April, 2006 through a structured interview and an open ended questionnaire.
The interview requested information regarding the instructions that the mothers received from the health professionals on breastfeeding immediately after delivery, the mother's feelings at not having breastfed, and their knowledge of the need for breastfeeding. In addition, the nursing staff at the rooming-in facility was consulted and information was obtained concerning the premature babies and their mothers during the hospitalization.
The answers to the questions were analyzed using thematic analysis to identify the emerging themes. The themes were subsequently counted as to the frequency with which they appeared in the data. Descriptive statistical techniques were used to quantify the answers and to report the results.
Prior to the data collection, authorization was granted by the UFRN Board of Ethics for Research, Protocol Nº 01/2006, in compliance with the Brazilian National Health Council's Resolution 196/96(14) that speaks to the protection of human rights in research involving human subjects. Signed informed consent was obtained from all the subjects after being advised of the purpose of the study, the data to be collected, and given assurances as to their anonymity, the confidential nature of the information, and the right to not participate in, or to abandon the study at any moment without compromising their health care.
a) Sample characteristics
Most of the 33 interviewed women were in the 16-21 age group (54.5%) and were married or living consensually with their partners (84.8%). As to their educational status, the women had undergone some formal education, either at elementary or high school level. The majority (69.7%) reported having complete or incomplete elementary education and 30.3% indicated complete or incomplete high school education. As to parity, 33.3% indicated having had 1 child, while 66.7% reported having 2-4 children.
b) Knowledge about breastfeeding
When questioned about whether they had received any information from the health professionals regarding breastfeeding immediately after delivery, the majority (66.7%) of the mothers responded negatively. Those that responded in the affirmative (33.3%) reported that the information received instructed them to feed their babies exclusively with breast milk up to the age of 6 months; that breast milk is rich and precious and that it prevents disease, both in the mother and the baby. In addition, they reported that they were taught feeding techniques as well as what items to avoid giving the baby, such as tea, water, and pacifiers, among others, during the six months of exclusive breastfeeding.
Not all the participants breastfed their babies immediately after delivery, however. The large majority (72.8%) justified this decision based on the baby's prematurity and on the fact that the baby was hospitalized in the NICU, while 27.2% reported that in addition to being premature, their babies were born with some pathology, requiring a longer hospitalization period that delayed the breastfeeding.
c) Feelings toward breastfeeding
The women reported that not being able to breastfeed their babies immediately after delivery caused a wide range of feelings. Among these were sorrow (51.5%), guilt (42.5%), disappointment (18.0%) and frustration (12.0%). These emotions lead to conflict when they assume a dominant form of expression.
However, the stressful negative feelings were overcome, in part, by those of fulfillment (45.4%) and pride (27.2%), derived from their first experience at breastfeeding in the rooming-in facility, after the baby's discharge from the NICU. Despite these positive feelings, however, they also felt insecure (21.1%) and fearful (6.0%) in breastfeeding their babies that were so small, delicate and helpless.
One of the factors that generate the most insecurity and guilt in mothers, especially when dealing with a premature baby, is the lack of knowledge concerning the breastfeeding process. However, the participants reaffirmed the need and the importance of breastfeeding. The reasons they reported breastfeeding as necessary were: it helps the baby to grow healthy (57.7%); it will be better for the mother's health (27.3%); it is economic for the family (9.0%) and it strengthens the mother/child bond (6.0%).
The women in this study saw themselves as being thrust into a world of conflict that unleashed a spectrum of negative feelings when they were confronted with the frail state of their premature infants that did not allow them to breastfeed. These were feelings of sorrow, guilt, disappointment and frustration. These feelings during the immediate post-delivery can be caused by the possibility of their babies not being physically normal, especially when there is some type of pathology that needs to be treated while in the NCIU. Upon discharge from the NCIU, however, and having enrolled in the rooming-in facility that is centered on the mother/infant contact care, these negative feelings gave way to more positive ones of fulfillment and pride as they experienced their first breastfeeding. Although feelings of insecurity and fear remain in the mothers' consciousness, they seemed to be knowledgeable of the value and the benefits of breastfeeding.
The early negative feelings can be explained by the idea that when the baby is born prematurely, the mother experiences guilt derived from the difference between the situation she is in and the situation she would like to be, between what she is doing and what she would like to be doing. The incongruent nature of the situation transforms her into an unhappy mother that results in the suffering of an inner conflict related to the prematurity of her baby, thereby resulting in some anxiety(1).
Anxiety is characterized by feelings of tension, anguish, and danger. The mother of a term baby frequently experiences anxiety related to doubts about her capacity to breastfeed, to take care of the baby, and to assume the great responsibility of raising a child. Therefore, anything unexpected, or out of the ordinary, such as a premature birth, can bring about the anxiety in the mother. In these cases, maternal anxiety may contribute to breastfeeding problems because the anxiety process acts negatively on the let-down milk reflex(1).
Feelings of frustration in the mother at not being able to cradle and/or cuddle her child are also greatly exacerbated by the separation occurring because of the internment in the NCIU. Also, the fear of touching and caressing the baby inside the incubator, or of holding it in her lap whenever possible, was a feeling reported by these mothers. This fear is not only related to the strange environment, but it is also possible that it is the result of a diminished self-esteem, fear of harming the baby, and a lack of confidence in the capacity to raise the baby(15).
Guilt is frequently caused by the often unconscious assumption that during pregnancy the mother did or did not do something that was required, that affected her baby and provoked prematurity. Due to prematurity, breastfeeding may be delayed, and as a result, the mother may develop strong guilt feelings and may be left with the sensation of not fulfilling her role(16). Thus, the desire to nurse the baby without being able to satisfactorily do so may provoke guilt. This is often accompanied by impotency feelings at the inability to remove obstacles such as the premature condition that may interfere in the breastfeeding.
These findings indicate that the mother/infant bonding, a strong and lasting emotional relationship, in the case of the premature newborn, as with the other term babies, initiates with the first breastfeeding experiences. Therefore, this practice must be undertaken as soon as possible, and every obstacle which could interfere in this contact must be removed. The early formation of this bond has great advantages as does the maintenance of breastfeeding until two years of age, a practice recommended by the World Health Organization.
In this study, the importance of the rooming-in facility as the environment for the development of the mother/infant bond became apparent. The rooming-in facility promotes the mother-infant contact that is so necessary for the success at breastfeeding. The opportunity that the mother has to hold the baby and to relate to it as her offspring can be helpful in diminishing the feelings of exclusion resulting from the NICU stay. Mothers that have their babies hospitalized in the intensive care experience feelings of exclusion when they have no interaction with their babies. They experience positive maternal feelings when they are allowed to participate in the care of their babies(17).
It is suggested that with the firming of the mother/child bond, there is a greater probability that the maternal feelings experienced while nursing the baby will be those of pleasure and pride. As a consequence, the baby will receive not only the mother's milk which nourishes the body, but also the good emotional milk which nourishes the soul(1).
It is also important to emphasize the role that breastfeeding advising and orientation play on the success of the mother's early experiences at nursing. This orientation and support needs to be continuous in order to overcome the continuous fears and insecure feelings that emerge throughout the care(5).
The results of this study indicate that it is important to recognize sorrow, guilt, disappointment, frustration, and insecurity as predominant feelings amongst the mothers of babies hospitalized in the NICU. These emotions are related to the breastfeeding conflicts they experience with their premature babies during their stay at the rooming-in facility.
Health professionals need to recognize that these feelings may not be so obvious to the observer because they are minimized, in part, by the expression of feelings of fulfillment and pride that occur when the mothers experience breastfeeding upon discharge from the NICU. The rooming-in facility therefore contributes to the emotional maternal/infant bonding established when the mother remains in the rooming-in facility.
It is suggested that a therapeutic area be set aside in the rooming-in facility of the institutions that provide NICU care. This area could be used for group interaction where mothers, accompanied by their premature babies undergoing treatment in the NICU, can express their anxieties, fears, and guilt, among other feelings. Such environment would provide conditions for the provision of a better quality of life for the mothers during the hospital stay with their babies. This experience could aid in developing baby care skills and in decreasing doubts that might occur upon hospital discharge.
It must also be pointed out that the support provided by a qualified team is not exclusive to interaction groups. This type of care must also occur during the daily nursing activities and throughout the care of the health team with transdisciplinary action.
In this context, and based on the feelings of the mothers found in this study, there is a need for trained health professionals to carry out interdisciplinary actions with the families. The aim would be to help them in the care and comfort of the premature newborn, while strengthening their confidence during hospitalization. It is vitally important that after hospital discharge, these mothers feel that they can provide safe care to the premature infant at home. Likewise, they should be encouraged to express their feelings, to relieve their anxieties, especially regarding the practice of breastfeeding.
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