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Texto & Contexto - Enfermagem

versão impressa ISSN 0104-0707versão On-line ISSN 1980-265X

Texto contexto - enferm. vol.27 no.1 Florianópolis  2018  Epub 05-Mar-2018

http://dx.doi.org/10.1590/0104-07072018000880016 

Original Article

UNVEILING THE LIVED EXPERIENCE MEANING OF BEING A WOMAN BREASTFEEDING WITH PUERPERAL COMPLICATIONS

Simone Pedrosa Lima1 

Evanguelia Kotzias Atherino dos Santos2 

Alacoque Lorenzini Erdmann3 

Ana Izabel Jatobá de Souza4 

1Ph.D. in Nursing. Nursing, Hospital Universitário Ana Bezerra, Universidade Federal do Rio Grande do Norte. Santa Cruz, Rio Grande do Norte, Brazil. E-mail: simone.ufrn@hotmail.com

2Ph.D. in Nursing. Professor, Department of Nursing and the Postgraduate Program in Nursing, Universidade Federal de Santa Catarina (UFSC). Florianópolis, Santa Catarina, Brazil. E-mail: gregos@matrix.com.br

3Ph.D. in Nursing. Professor, Department of Nursing and the Postgraduate Program in Nursing, UFSC. Florianópolis, Santa Catarina, Brazil. E-mail: alacoque@newsite.com.br

4Ph.D. in Nursing. Professor, Department of Nursing and the Postgraduate Program in Gestão do Cuidado em Enfermagem, UFSC. Florianópolis, Santa Catarina, Brazil. E-mail: jatobá.izabel@ufsc.br


ABSTRACT

Objective:

understanding the lived experience meaning of being a woman breastfeeding with puerperal complications.

Method:

a qualitative study of phenomenological nature based on the phenomenology of perception and on hermeneutics. Data collection took place in two maternity hospitals in the Northeast Region of Brazil from February to October 2014, through in-depth interviews with 28 women who had recently given birth. Data analysis included: reading descriptions, identifying thematic units and essential themes.

Results:

a central meaning emerged from the description analysis of breastfeeding being more important than the situation experienced in puerperal complications; and essential themes of perceiving family support and perceived feelings when experiencing breastfeeding with complications.

Conclusion:

the study created the opportunity to understand that breastfeeding experienced being a woman with puerperal complications is composed by a series of meanings, and knowledge of these meanings by health professionals can contribute to more comprehensive care.

DESCRIPTORS: Breastfeeding; Puerperium; Women's health; Qualitative research; Nursing

RESUMO

Objetivo:

compreender o significado da experiência vivida para o ser-mulher na amamentação com complicações puerperais.

Método:

estudo qualitativo, de natureza fenomenológica, sustentado na fenomenologia da percepção e na hermenêutica. A coleta de dados ocorreu em duas maternidades da Região Nordeste do Brasil, por meio de entrevistas em profundidade com 28 puérperas, de fevereiro a outubro de 2014. A análise dos dados compreendeu: leitura das descrições, identificação das unidades temáticas e dos temas essenciais.

Resultados:

da análise das descrições emergiu como significado central: amamentar é mais importante do que a situação vivenciada na complicação puerperal, e como temas essenciais: percebendo o apoio da família e sentimentos percebidos ao vivenciar a amamentação com complicação.

Conclusão:

o estudo oportunizou compreender que a amamentação vivenciada pelo ser-mulher com complicação puerperal é composta por um conjunto de significados, e o conhecimento destes pelos profissionais de saúde, poderá contribuir para um cuidado mais integral.

DESCRITORES: Aleitamento materno; Puerpério; Saúde da mulher; Pesquisa qualitativa; Enfermagem

RESUMEN

Objetivo:

comprender el significado de la experiencia vivida de ser mujer lactante con complicaciones puerperales.

Método:

estudio cualitativo de naturaleza fenomenológica, con el apoyo de la fenomenología de la percepción y la hermenéutica. La recolección de datos se produjo en dos hospitales en el noreste de Brasil, a través de entrevistas a profundidad con 28 madres, de febrero a octubre de 2014. El análisis de datos incluyó: lectura de las descripciones, identificación de las unidades temáticas y de los temas esenciales.

Resultados:

del análisis de las descripciones surgieron como significado central: la lactancia materna es más importante que la situación vivida en las complicaciones del puerperio, y otros temas esenciales como: percibiendo el apoyo de la familia y sentimientos percibidos al vivenciar la lactancia con complicaciones.

Conclusión:

el estudio proporcionó una oportunidad de comprender que la lactancia materna experimentada por el ser-mujer con complicaciones puerperales se compone de un conjunto de significados, y su conocimiento por parte de los profesionales de la salud, puede contribuir a una atención más integral.

DESCRIPTORES: Lactancia materna; Puerperio; Salud de la mujer; Investigación cualitativa; Enfermería

INTRODUCTION

Infant mortality is a relevant indicator of public health, and fighting it has been a goal for the entire planet. In Brazil in particular, the report published by the World Health Organization (WHO) entitled "Levels and trends in infant mortality 2015" shows that the death rate among Brazilian children under five years old increased from 61 deaths for each 1,000 children born alive in 1990, to 16 deaths by 2015; a decrease of 73 percent over the past 25 years.1 Positive results around the world are due to the increase in low-cost, evidence-based interventions such as access to vaccines, adequate breastfeeding, nutritional supplements and food therapy, oral rehydration for cases of diarrhea, and greater access to drinking water and sanitation, among others.2-3

Breastfeeding is responsible for reducing the death of children under five years old from preventable causes up to 13%.4-5 However, despite all the scientifically proven advantages, breastfeeding practice is far below recommended levels, as the mean of exclusive breastfeeding in our country is 54.1 days, and the average time of breastfeeding Brazilian children between 9 and 11 months is 341.6 days.4,6 Breastfeeding is a multidimensional act that includes biological, socioeconomic, cultural and family aspects. Due to this complexity, the success of this practice requires the efforts of society as a whole; not only governmental efforts, but also involving formal and informal support networks and family members, as well as health professionals. Health professionals need a comprehensive approach in guiding mothers and helping them gain self-confidence in breastfeeding, which means they must provide care that covers all aspects of breastfeeding which contributes to reducing early weaning.6-7

Specific issues of the puerperium are added to the complexity of breastfeeding, since woman undergo local and systemic modifications during this period aimed at returning to their pre-pregnancy period physiology. These transformations involve hormonal, genital and emotional aspects, making the puerperium a delicate period in which women are susceptible to certain aggravations both of endogenous and exogenous origins, denoting puerperal complications.8

Thus, when reflecting about the importance and complexity of breastfeeding, the specificities that involve the puerperium, including those that evolve with complications coupled with the scarcity of studies that approach the theme, concerns and questions are raised about the experience of women who are breastfeeding while experiencing puerperal complications. These concerns also arise from the relevance of the role that health professionals, particularly nursing professionals, play in promoting, protecting and supporting breastfeeding, as well as the care given to women in the pregnancy-puerperal cycle. This care should be guided by ethical, technical and quality principles, enriched with the ability to listen, valuing the human being in their entirety.

With the aim of contributing to this form of care, the present study was guided by the following guiding question: what is the lived experience meaning of being a woman breastfeeding with puerperal complications? The aim of this study was established in searching for answers to such questioning to understand the meaning of the experience lived being a women during breastfeeding with puerperal complications.

METHOD

This is a qualitative study, with theoretical-philosophical reference in Merleauponty's phenomenology of perception9 and methodological reference in hermeneutic phenomenology.10 The phenomenological method is an attitude of involvement with the world of lived experiences. By putting lived experience as a reference for theoretical systematization, phenomenology undoes the main postulate of modernity: rationalism. The predominance of excluding reason is replaced by the lived world, involving the reflected and the unreflected, the visible and the invisible.11

The concept guiding this study was that perception is "the background upon which all acts stand out and is presupposed by them. "The world is the field for my thoughts and my perceptions, because man is in the world, and it is in the world that he knows himself".9:6 In this perspective, the subjects of experience are destined for the world, and it is through the body that we know what happens around it; body postures are what provide a notion of our relations with things and other bodies at each moment.

For the philosopher, the body is not a mere organic object in the world, and neither is it an idea, it is a body of living experience. Therefore, to express oneself in the world of a body, the movement of that same body not only provides man's contact with the world, but it makes him become a being in the world.9 Based on the philosopher's conceptualization, the present study adopted the term 'being a woman'.

The experimental descriptions composing this study were obtained in two public maternity hospitals in the Northeast Region of Brazil from February to October 2014, from interviews of 28 women breastfeeding with a diagnosis of puerperal complications, and with these constituting the inclusion criteria. Women who had just given birth and who did not have the physical, emotional and physiological conditions to perform the interview were excluded. The guiding question for the research was: what does it mean for you, the being a woman, experiencing breastfeeding with puerperal complications? Subjects' names have been replaced by the names of women who are quoted in the bible in order to ensure their anonymity. The interviews lasted around 30 minutes and were concluded when there was repetition in testimony content (data saturation).

The analysis followed the following steps10 which were adapted:12 exhaustive reading of the material; thematic analysis, in which the material was read line by line, reflecting on what a specific sentence or a group of sentences revealed about the studied phenomenon constituting thematic units; and finally convergence was sought between the thematic units, and essential themes from the data sets were identified. Next, phenomenological reflection was carried out based on the Merleaupontyana conceptions and on the methodological framework chosen for the study10 aimed at understanding the lived experience meaning of being a woman breastfeeding with puerperal complications.

The research was conducted in accordance with the ethical standards required by Resolution N. 466/2012 of the National Health Council, being authorized by the combined opinion numbers of 485.322 and CAAE 23099913.8.0000.0121 of the Ethics Committee on Research with Human Beings of the Federal University of Santa Catarina. All the interviews were recorded with the participants' agreement on a digital recorder and later transcribed in full and submitted to analysis.

RESULTS AND DISCUSSION

A central meaning of "Breastfeeding is more important than the situation experienced in the puerperal complication" emerged from the experiential descriptions. Essential themes that relate to and converge towards the central meaning also emerged from the experiential descriptions, which together reveal the experience of women with puerperal complications breastfeeding. Thus, the themes that arose were "Perceiving family support" and "Perceived feelings when experiencing complications during breastfeeding."

Breastfeeding is more important than the situation experienced in puerperal complications

Being a woman expressing the meaning of breastfeeding with complications highlights two motivations that corroborate breastfeeding continuity, even experiencing discomfort and limitations imposed by puerperal complication. The first motivation relates to the fact that breastfeeding is more important than any adversity she might be facing. In the interviewees' speeches, there is yet another motivation that justifies breastfeeding, which is the value attributed to motherhood, more precisely maternal love. Then, to better understand the first motivation, excerpts were extracted that portray the relevance of breastfeeding against the discomfort caused by puerperal complication.

When he came near me I put him on my chest, I could not take him off anymore, I was always breastfeeding, even when I arrived at the maternity hospital bleeding I was breastfeeding because I knew that if my baby breastfed he would be well and that was the most important thing for me. The most important thing for his health was the milk (Dorcas).

It's bad, it hurts, then it goes away. It's hard to walk, to sit, ouch, everything hurts. As the pain doesn't go away I have to endure it because I have to breastfeed him with my milk so my son will grow strong and healthy. We have to breastfeed, think about him and forget about myself. I have to breastfeed him until he grows up. I forget everything, even the pain (Débora).

To tell you the truth, I breastfeed against my will as if I were obliged to because I have no desire to do so [...]. I do it because it's my obligation [crying, a lot of crying]. For the sake of my daughter's well-being, it is only for her good (Lídia).

Breastfeeding is an act that transcends biological issues. There is a tangible subject in this process, a being who sees, expresses feelings, interacts with herself, with others and with the environment. Consequently, a woman's decision to breastfeed is linked to her life history, the values that are passed on culturally, as well as the health education opportunities she has had throughout her life. Particularly in Brazil, information has been widespread regarding the importance of breastfeeding in recent decades. In 1981, the Brazilian Ministry of Health launched the Breastfeeding Incentive Program, and over the years this Program was strengthened and expanded through other initiatives and strategies such as the Child's Friend Hospital (Hospital Amigo da Criança) and the Feed Brazil Strategy (Estratégia Alimenta Brasil) initiatives.13

The results of these efforts were demonstrated in surveys carried out in 1999 and 2008, which point towards a growth in exclusive breastfeeding among children from zero to four months old, from 35.5 to 51.2%, respectively.4,6 In this study, women reported on the importance of breastfeeding, showing a human being that interacts with the world and introjects values that are passed on culturally and socially. Thus, they revealed in their speech that knowledge about immunological and nutritional benefits are factors that influence their decision to breastfeed, and for some the perceptions about these benefits are so intense that breastfeeding becomes a mandatory practice. Based on what they believe about breast milk, they endure pain, high fever and bleeding because what mattered at that moment to these women were their children, their well-being.

Therefore, in the speeches there is an ambiguity about the breastfeeding experienced by being a woman with puerperal complications. In speeches, there are those who breastfeed with joy and pleasure, recognizing the importance of breastfeeding. On the other hand, there were women who had just given birth who felt strongly obliged to do so, even though it caused suffering during breastfeeding. Both in breastfeeding with joy and pleasure and in situations that refer to the obligation to breastfeed, the woman forgets about herself and her body, about her own existence. It is as if there is another being living in the same body, revealing a new way of being - consumed by the concerns of the baby's health and well-being.

Between my consciousness and my living body, my phenomenal body, and someone else's, as I see from the outside an internal relationship takes place, which makes the other appear as the finishing of the system. In other words, the system is formed by someone else's body and mine, which are considered a single whole, the verse and the reverse of a single phenomenon.9 The sense of existence of being a woman who nurses with puerperal complication is legitimized by their relationship with the child. This aspect is strengthened in discourses that justify breastfeeding as a form of demonstrating love and affection.

Breastfeeding is love , you give him love. Several times I came from far away, under rain and sun to breastfeed him. I do not regret it. My wound opened, but the emotion of being with my son, of carrying him, has no explanation (Noemi).

Research also points to breastfeeding as a channel of communication and manifestation of love, creating an emotional bond between mother and child;13-14 it is based on the premise that consciousness always has an intention and by understanding that the woman's act of breastfeeding with puerperal complication while enduring discomfort is conscious and focused on the child, a sign of maternal love. In this sense, from an active and intentional consciousness, being a woman with puerperal complications experiences breastfeeding with love, and uses all the resources she possesses: bearing pain, open wounds, difficulties of movement, and all in the name of this true love; a love confirmed by the act of breastfeeding, which stems from her being.

Perceiving family support

The family is perceived being a woman through physical presence, focused on two aspects. The first refers to the care taken and given by relatives to the newborns, other children and to the woman. The second was a sense of strength and self-esteem improvement, which flowed from the family members providing for exchanges between women and her family. The following statements corroborate these reflections.

The support of the family is very important, without their support I would not have been able to stay at the hospital. The day my mother went home and I was by myself I got sick. I got sick because I knew I did not have the capacity to take care of him, I could not get him out of the crib. Getting out of the bed is a sacrifice, I had to drag myself [...]. I would get up and it looked like it was going to open, and it gave me such strong pain, so the family was very important to me. My partner stayed home taking care of my two daughters (Maria Madalena).

The experience of being a woman with puerperal complications is marked by the discomfort caused by the symptoms and consequent impossibility of caring for her own self, the newborn and the children who stayed at home. In this sense, the care provided by the family becomes inestimable for the woman, since routine actions such as changing diapers, picking up the baby from the crib, or even caring for her other children can no longer be performed by women experiencing complications. Women feel incapacitated, but the fact that these caring actions are taken up by relatives is interpreted as important, and it is also a factor that contributes to their stay at the hospital. Other studies confirm the relevance of the family in the puerperal period, with family assistance making a significant contribution in this period.15-17 In addition to the care provided, relatives appear in the interviewees' speeches as a source of strength.

They were very concerned and stayed there with me all the time. It was important because it helps to improve my mood, self-esteem; helps to improve my health (Joquebede).

As my family, which is my source of strength, looked at me like I could die at any moment, it made me feel awful. I understand their fear, I would feel the same [...]. But I must start over [...] because everyone is afraid of when I go home. They think that when I get home I'll get sick again, and that I would have to be carried [...]. If these people who live with me are looking at me this way, how can I handle it? How can I overcome this and change my own mentality? But I know I have to overcome it for my family, children. The desire to stay with them made me struggle for everything that really matters, for my family [...] (Dorcas).

Relatives are perceived as those who influence health recovery, because when interacting with women they feel a sensation described as a force that drives them to fight. In this study, we also found opposite repercussions that the family causes to women. When faced with diversity present in puerperal complications, they demonstrate fear and disrepute toward reestablishing the health of the puerperal woman. However, despite the fact that the woman recognizes these feelings and feels influenced by them, she also states that a willingness to fight comes from the family. Thus, within the lines there is a network of meanings that converge into an incarnated body that is integrated with the world, in which it interacts and reacts to the other.

The body has an enigmatic nature, because it is not a gathering of particles of which each would remain in itself or as a mixture of definite processes once and for all. The body protrudes into its material surroundings and communicates to other incarnated subjects.9 Thus, in sharing its world with its relatives, a woman who has just given birth acquires a consciousness that is conceived as perceptive. In other words, as the subject of a behavior anchored in the world, the other appears at the summit of his/her phenomenal body and receives a location.9 This location that the relatives found in the body of the woman was translated and perceived by them as a force that has caused non-conformist movements with the experienced situation, not only seeking a cure for the physical suffering, but also the emotional suffering caused by the puerperal complications.

Feelings perceived when experiencing breastfeeding with complications

The feelings expressed and reported by the interviewees such as sadness, despair, frustration, denial and missing, are directly related to the disease process and the hospitalization that occurred due to the clinical situation worsening. Fear was one of the most intense feelings, with reference to fear of pain, death and contamination of the baby through breast milk. The following testimonies exemplify the feelings listed.

[...] very bad ... I cried a lot [...], but I had to stay there to take medicine and get well soon. I did not want to stay with her in the hospital, to sleep there [...] I did not want to, it was very bad. It was all in my head, a bad feeling. Thus, there are no words to describe it; it feels spiritless, a negative mood. It has no explanation, there is no joy, no laughter. There was only her who was there with me and that was the best thing (Joquebede).

[...] a fear of pain. At night, moaning and feeling pain, fever. I could not even get out of bed to go to the bathroom. I am afraid it will happen again (Tamar).

Every day I cry, thinking I'm going to have another surgery. After my abdomen opened, I thought I was going to die and left my children there abandoned. Every night I cry afraid [...] [cry]. Afraid of leaving my son abandoned, without anyone being able to take care of him, I only think of him (Rebeca).

The perceived suffering in the statements of the woman with complications and the crying expressed during the interviews are attributed to the hospitalization process, which is mainly represented by separation from their children, fear of death and the pain caused by the infectious process. Rejection of hospitalization is clear, and the fear of death does not arise as a fear of death itself, but as a threat that can separate mothers from their children. Therefore, fear has in its essence a motherly face, something instinctive, of protection and care for the children.

Regarding the emotional reactions resulting from the experience of being sick and hospitalized, a study carried out in different age groups and pathology demonstrates aspects similar to those found in the present study. Sadness, suffering, crying, nervousness, aggression, loss of freedom, concern for relatives and fear of early death are some of the reactions listed.18

Another exposed feeling is the fear of passing the infection through the milk, as well as the fear of harming the baby with the antibiotics used throughout the treatment for the complications.

During this time, I thought about the infection that occurred in the blood and I thought I would pass it on to my girl, because it was in the blood, and the milk came from the blood, but I still continued to breastfeed during the time I spent at home (Lia).

I thought my milk could harm her, because when I started taking antibiotics she did not want to breastfeed. I continued to breastfeed her because the doctor said it was not harmful (Sulamita).

In the mind of the being a woman, mother's milk is produced from her blood, and as one of the tests performed to confirm the infection diagnosis is a blood exam, she makes a direct association between the two facts, leading her to believe that it is possible to infect the child through her milk. In this logic, from the mothers' perception, it is also true that the ingested antibiotics present a risk for the babies. Although this insecurity and fear are present in the experience of being a woman with complications, there are national manuals directed to health professionals that deal with the safe use of drugs during breastfeeding. In this sense, an enlightening dialogue between the woman and the health team is of paramount importance, since it will calm them and provide credibility, thus contributing to breastfeeding continuity, as demonstrated in the report highlighted in this study.5

As we reflect on the meanings attributed by being a woman in this unit, we realize that all the feelings and reactions experienced in her body are products of her perception of the meaning of being sick and of the hospital environment; that is, of an environment external to her body.

Particularly in the hospital setting there is a cultural world, a diversity of meanings which re represented by pain, disease, suffering, separation and death. There is not only a physical world around us composed of air, water and land, there is also a cultural world represented by plantations, towns, streets, and churches; each of which represents human action to which it relates. The civilization that we are a part of exists for us through the instruments that it possesses. The instruments present in that culture represent a multiplicity of I; that is, before the vestiges of a disappeared civilization, we idealized an analogy of the species of man who lived there. "In the cultural object, I feel the presence of another, under a veil of anonymity."9:466

In the hospital setting, the being a woman experiences this cultural world, feels the presence of other people who suffered there. The instruments that are there, medicine, beds, incubators and hospital devices lead the subjects of this study to return to the meanings of the hospital in the society in which we are inserted.

CONCLUSION

This study sought to understand the meaning of the experience lived being a woman while breastfeeding with puerperal complications. In this context, breastfeeding experienced being a woman with puerperal complications is composed of a set of meanings, which arise from a body that is not only composed of the biological aspect, but a body that exists from its insertion in the world, from the relationships established with herself and with others. Thus, these meanings are revealed through breastfeeding that overcomes the discomfort caused by the complications, in which there are strong feelings related to hospitalization and the family consists of an important turning point in this context, since it is a source of care and strength for the being a woman.

With these meanings as a starting point, it is possible to plan care guided by the lived experience of being a woman, focused on actions that go beyond the technical issues directed to the ill body. In this sense, care will not be directed towards a subject itself, but will be guided by the encounter of being a woman with her experiences and the encounter of her experiences with other people's, which means care permeated by subjectivity and intersubjectivity, which are embodied in an incarnated body. These reflections allow professionals to acquire a broad view about the phenomenon of breastfeeding in the context of complications; a view constructed from the perception of the women who live the experience, and it is possible to identify elements that may strengthen or weaken the practice of breastfeeding.

Potentialities in identifying that being a woman, even when experiencing pain and discomfort, chooses to breastfeed because in motherhood and consequently in breastfeeding, there is another being that lives in the woman's body which legitimizes her existence through maternal love. This meaning may, for example, assist health professionals and particularly nurses in exercising educational actions, and as an additional argument for breastfeeding. Another potentiality present in the experiential descriptions is the role that the family members play in this context, constituting themselves as collaborators in the care of the being a woman, since they extend the human existence of the women who have just given birth. In this way, professionals must involve them in the care, stimulating them to understand the interaction between them and the being a woman, and the consequent influence they exert on the daily life of the puerperal woman. This understanding is necessary, as family members when guided can be added to the health team regarding the protection and encouragement of breastfeeding.

Elements that may cause weakening essentially concern hospitalization, a situation marked by feelings of sadness, despair, frustration, denial and missing, as well as fears of pain, death, and transmitting illness/disease to the infant when breastfeeding. These feelings need to be perceived by the team who provide assistance in order to plan actions that will minimize them, because in the long run they may contribute to discouraging breastfeeding. By valuing the described elements, health professionals can provide care to breastfeeding women who have complications permeated by comprehensiveness, opposing the fragmented view of Cartesian thinking; in addition, actions aimed at reducing early weaning, and consequently infant mortality.

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Received: April 05, 2016; Accepted: February 03, 2017

Correspondence: Simone Pedrosa Lima. Universidade Federal do Rio Grande do Norte, Praça Tequinha Farias, 13, 59200-000 - Santa Cruz RN. E-mail: simone.ufrn@hotmail.com

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