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Revista Gaúcha de Enfermagem

On-line version ISSN 1983-1447

Rev. Gaúcha Enferm. vol.36 no.spe Porto Alegre  2015

http://dx.doi.org/10.1590/1983-1447.2015.esp.56766 

Original Articles

Breastfeeding and complications that contribute to early weaning

Carolina Sampaio de Oliveiraa 

Fátima Aparecida Ioccaa 

Mona Lisa Rezende Carrijoa 

Rodrine de Almeida Teixeira Mattos Garciaa 

a Universidade do Estado de Mato Grosso (UNEMAT), Faculdade de Ciências da Saúde, Curso de Enfermagem. Cáceres, Mato Grosso, Brasil.

ABSTRACT

Objective

To obtain knowledge on the experience of mothers about breastfeeding and events that contribute to early weaning.

Method

research descriptive and exploratory kind with a qualitative approach carried out in a unit of the Family Health Strategy in the city of Cáceres-MT, through semi-structured interviews with 21 women who gave birth from January / 2012 to January / 2014.

Results

The data showed that at six months only 19.1% of the children were still being exclusively breastfed and the main explanations for this were: Lack of knowledge, inexperience / insecurity; Underestimation of maternal distress; Complications of puerperal breast; Family interference; Weak / inadequate milk; maternal employment.

Conclusion

The study reinforced the need for adjustments in the current care model, surpassing applicability of predefined techniques, encouraging critical judgment and perception of health professionals regarding the the construction of new knowledge and behaviors.

Key words: Breastfeeding; Weaning; Maternal-child nursing; Millennium Development Goals

INTRODUCTION

In order to address the emerging concerns that impact mankind, during the Millennium Summit of the United Nations held in 2000 by the international community, eight Millennium Development Goals (MDG) were proposed for the priority areas of health, education and elimination of extreme poverty in the nations, including targets and indicators aimed to reduce social and inequalities and improve the quality of life of people. These goals should be fulfilled by 2015. The proposal was endorsed by the leaders of the countries affiliated to the UN, through the civilizing pact known as Millennium Statement, and the proposed goals were: 1- Eradicate extreme poverty and hunger; 2 - Achieve universal primary education; 3 - Promote gender equality and empower women; 4 - Reduce child mortality; 5 - Improve maternal health; 6 - Combat HIV/AIDS, malaria, and other diseases, 7 - Ensure environmental sustainability; 8 - Develop a global partnership for development (1). In view of the aforementioned, the importance of breastfeeding as a strategy inserted with the scope of the ODM should be stressed, as follows: BF in the early years of life plays a key role in the fight against poverty and malnutrition, often ensuring the survival of children, particularly those who live in unfavorable conditions. Breast milk is the best source of nutrition for children at this age range, providing several immunological and psychological benefits; and when associated to complementary quality food after 6 months of age, as recommended by the Ministry of Health, it maximizes the healthy development of children(2).

In addition to the aforementioned short and medium-term beneficial effects, a prospective cohort study with 3,493 participants followed-up for a 30-year period, conducted in Southern Brazil, concluded that breastfeeding for more than 12 months would have a positive impact on the cognitive development of children. This finding deserves to be highlighted, since the long-chain fatty acids in breast milk are important lipid components for the development of cell membranes, including the central nervous system, contributing to brain development and increased intellectual abilities in adulthood, resulting in a higher educational level and financial income (3).

In the United Kingdom, a study with mothers of term and late preterm infants indicated that in both cases the mothers who received guidance by support groups in the hospital were more likely to breastfeed for a longer period. However, the mothers who reported receiving little guidance were less likely to breastfeed longer (4). Another study in the United Kingdom with mothers that attended Baby Café showed that many aspects related to breastfeeding mentioned by professional during their pregnancy were found to be inconsistent with reality of postpartum, and, thus, these mothers feel unprepared when they face unexpected situations. These mothers also emphasized the importance of a good prenatal monitoring, with paternal involvement, particularly in the immediate postnatal week and that all women had access to these appointments (5).

Since the mid-eighties Brazil has been experiencing continuous changes in the organization of the health services, which has affected the social determinants of the disease, such as indicators of maternal health and infant health and nutrition, with emphasis on changes in care, providing access to most health interventions, with almost universal coverage of this target population. This leads to positive results related to the average increase of breastfeeding and in reducing infant mortality rates substantially (6). However, despite the many advances, important challenges persist regarding this topic and the pursuit of reducing early weaning and improving maternal and child quality of life.

In view of the findings presented by MDG 2013 report, elaborated by the UN, the world, the global rate of infant mortality (children under 5 years) decreased by 47% in 22 years; nevertheless, the target of for MDG 4 is to achieve a reduction of 75%, between the years 1990 to 2015. This goal has been achieved in Brazil. The National Monitoring Report on the MDG 2013 showed reduction in infant mortality rate from 53.7, in 1990, to 17.7 deaths per thousand live births, in 2011, for children under 5 years, and for children under one year, the number of deaths was reduced from 47.1, in 1990, to 15.3, in 2011, per thousand live births (7).

The UNICEF (8) estimates that nearly half of all infant deaths under one year of age occur in the first week of life (49.4%)., suggesting that the introduction of breastfeeding soon after birth can substantially reduce neonatal mortality, which is the death that occurs within the first 28th days of the child’s life (65,6%). The UNICEF adds that if breastfeeding continues up to the sixth month of life, it can prevent 1.3 million deaths in the age group up to 5 years.

Breastfeeding is also beneficial for women’s health, protecting them from diseases like breast cancer, ovarian cancers and bone fractures caused by osteoporosis, provides faster uterine evolution due to the release of oxytocin, resulting in less postpartum uterine bleeding, which contributes to reduce anemia. Effective breastfeeding leads to a longer intergestational period, because of the longer amenorrhea, favoring faster loss of weight gained during pregnancy compared to women who do no breastfeed (2). Besides providing a special time of bonding between mother and child, breastfeeding also produces a positive impact on their health and contributes to the creation of an environment of trust and affection that favors the transformation of these children in self-assured and confident adults.

So far, there are no studies that categorically state the benefits of breastfeeding in fighting AIDS and the other diseases. Some studies in South African countries affirmed that breastfeeding has increased survival of children up to two years. However, in view of the aggravating factors of infant mortality, such as shortage of food and drinking water, viral load tests of the mothers should be performed. The Brazilian Ministry of Health does not recommend breastfeeding to children born to HIV positive patients (2).

Breastfeeding also contributes positively to environmental sustainability. Weaning has many impacts on the planet, including deforestation to raise milk cattle and its consequent pollutants. It is estimated that the methane gas released through feces and farts of the herds has a significant impact on air pollution, accounting for around 20% of these greenhouse emissions, besides contributing to the formation of acid rain by the reaction of ammonia in the pens, since the animal feces and the sulfur in the air contribute to the contamination of groundwater. Other costly expenses incurred in the production of lactiferous food used in infant diet are the production of bottles, teats, accessories, cans and their labels ( materials that are often not recycled) and the costs for preparing and cleaning these materials (9).

Therefore, effective nursing actions aimed to encourage exclusive breastfeeding up to six months are essential, as recommended by the WHO. Thereby, the following question is posed: What are the questions of mothers related to breastfeeding and the events that contribute to the failure of breastfeeding?

In view of the aforementioned, the present study aimed to shed light on the mothers’ experiences regarding breastfeeding and the events that lead to early weaning.

METHODOLOGY

Descriptive and exploratory study with a qualitative approach based on a research for a Nursing term paper (10), conducted in the Family Health strategy (FHS) unit located in the city of Cáceres – MT.

The subjects of the study were 21 women who gave birth from January/2012 to January/2014. The participants had to meet the following inclusion criteria: over 18 years old, enrolled in the FHS unit of the city of Cáceres and giving birth in the reference hospital for obstetric care under the SUS network of the referred municipality. Women under the age of 18 who did not live in the FHS coverage area at the time of the interviews were excluded from the study. The identification of the group of participants, through SISPRENATAL records, was mediated by the nurse of the FHS unit.

Data collection was performed in the unit itself on days scheduled for children appointments and immunization, and by prescheduled home visits for the mothers who failed to participate in the activities of the FHS unit during the data collection period. Semistructured interviews were used for data collection with full transcript of the statements of the participants. The selected instrument favors the description of social phenomena and facilitates their explanation and full understanding.

The strategy used for data interpretation was content analysis of Bardin (11), comprising three stages, as follows: pre-analysis: transcription of the statements of the participants using a selected data collection instrument, floating reading and formation of a representative research corpus, systematization of the transcribed ideas, formulation of the hypotheses and objectives that guided the elaboration of the indicators to be used in data interpretation. Investigation of the material through coding into categories, and the last stage was the processing of the results through inference and interpretation, based on the theoretical framework.

Thus, the following categories were identified from data analysis: lack of knowledge, inexperience/insecurity of mothers; underestimation of maternal distress by the health team, breast soreness; family interference; weak or insufficient breast milk and job-related issues.

The research was approved by the Research Ethics Committee of Universidade do Estado do Mato Grosso – UNEMAT, under no 874.100, CAAE 36864014.2.0000.5166. To ensure the anonymity of the participants, according to the Free Informed Consent Form, the statements were identified by letter A followed by Arabic numbers.

RESULT AND DISCUSSION

Characterization of the subjects

The participants were 21 women aged 18-36, with complete primary education or incomplete secondary education; 6 participants were single and 6 others did not live with the child’s father, the others were married; nine were primiparous experiencing puerperium and breastfeeding for the first time; 10 women performed some kind of paid work during pregnancy; however, only 13 were entitled to maternal leave. Eight women returned to work before their children were six months old.

Lack of knowledge, inexperience and insecurity of mothers

Information can be disseminated through the several available communication technologies, providing access to knowledge; in turn, knowledge consists in the combination of ideas and learning that guide and support the actions carried out in different areas, in order to promote innovation and behavioral changes. However, when it comes to breastfeeding, the information conveyed is often insufficient, reaffirming the benefits of breast milk for children’s health, minimizing the role of the mother in this event and, thus, failing to provide the necessary guidance on the correct techniques of preparation of the breasts and the conducts relevant to breastfeeding.

Accoding to the statements of the participants inexperience associated to insufficient knowledge of breastfeeding could be directly or indirectly related to the fact that the mothers were not confident that their milk could be the only food for their children, or even to an attempt to seek solutions for breastfeeding related problems. The first solution adopted by mothers was often the introduction of formula feeding to their babies, because it can be easily obtained and administered to the infants. However, formula feeding is often administered on a permanent basis, contributing to partial or total early weaning, as it can be seen in the following statements:

[...] he cried too much, spent a long time latched on my breast, so I gave him the bottle with artificial milk bought in the market, just like my sister did [...] (A20)

[...] when I left the hospital and went home, I was alone with my baby and he was crying a lot; I tried to position him to breast feed, in the way the nurse told me to do, but he would sleep and wake up soon hungry, and I did not know what to do [...] (A21)

The information arising from knowledge grounded in scientific evidence about breastfeeding during the postpartum period were insufficient to generate confidence among these women. Understanding the importance of breastfeeding as a factor that goes beyond the infants is essential to preserve breastfeeding. In this context, health professionals play a key role, since they are supposed to provide appropriate care to these women, listening to their questions without making judgments, and without prejudices, to ensure the establishment of a bond with the patient. Such bond is necessary to provide appropriate care to pregnant women and their families, facilitating their access to health services and providing greater reliability of the information and guidance at this unique moment in the lives of the families (12).

Underestimation of maternal distress by the health care team

Underestimation of the feelings of postpartum women by the health team was easily identified in their statements. The participants, particularly primiparous women, were facing a new world full of uncertainties after the birth of their children; Postpartum women feel insecure and need support and guidance from people close to them regarding the first care to their infants. Health professionals must be well trained to provide humanized and individualized care to these women.

[...] I tried to breastfeed, but failed; I could see them looking at me strangely, so I did not ask them for help [...] (A5).

[...]I asked a woman who was in my room to help me, because the only thing the nurse said to me is that I should keep trying to make my baby suckle [...] (A12).

[...] I wanted and needed help, but the nurses only told me to position the baby to breast feed and kept walking back and forth [...] (A19).

An integrative literature review on support to breastfeeding showed that women seek health professionals to help them with their problems related to breastfeeding, but sometimes all they get is a flood of recommendations on the use of standards and rules that are not part of the daily lives of the mothers, generating fear and insecurity. Health professionals should try to focus on the daily experiences of postpartum women, helping them to identify the best actions for the promotion of healthy breastfeeding (13).

Another study on the interaction of health professionals and mothers conducted in the inland of São Paulo, in a Neonatal Intensive Care Unit showed that the assistance provided by health professionals is not always positive and pleasant. The participants of that study reported that their relationships with health professionals were often permeated by discomfort, suffering and uncertainty, with negative consequences for maternal recognition, autonomy and self-esteem (14).

Breast complications during the postpartum period

Breast problems are among the main factors leading to early weaning. The type of nipple has impact on breastfeeding, but does not prevent it. Breast complications during the postpartum period can be reversed with proper latch-on techniques (15). The mothers often report situations that demonstrate their unpreparedness to breastfeed, difficulties in the lactation process such as inverted or flat nipples, cracked nipples and mastitis, as follows:

[...] I felt a lot of pain when my baby started to suckle, and I cried along with him; it was very difficult for me because my nipples were inverted. So I used a syringe as a nipple puller, but this hurt me ...] (A3).

[...] my daughter was suckling all day, my breasts were always sore, so I bottle fed her until I got better, because I could not take it any more [...] (A11).

A study on the profile of women affected by severe lactational mastitis conducted in the inland of São Paulo showed that most women were young, primiparous, with complete secondary education, lived without a partner and did not work outside the home. Of these, 96.5% had some sort of breast complication before hospitalization and stayed in the hospital in average 4.4 days. At discharge, 23.7% of the women had already weaned their babies (15).

Also, the lactating mothers who suffered from severe lactational mastitis reported the existence of signs of problems related to breastfeeding such as nipple injuries, breast engorgement, fever, difficulty breastfeeding, which are not good signs, but can be quickly resolved to prevent its worsening (15).

Thus, the women who participated in this study reported continuing difficulties in breastfeeding, having to overcome physical pain because breastfeeding is important to promote the health of their infants.

Family interferences

In this study, maternal grandmothers do not favor the maintenance of breastfeeding, particularly exclusive breastfeeding. They possess a cultural heritage based on the empirical knowledge of their ancestors and attempt to convey this their common sense knowledge to the new generations. However, these actions are not consistent with the most sound scientific evidence that should be adopted by mothers relating to breastfeeding and infant care.

[...] my mother gave plenty of tea to my baby daughter because of her painful cramps in the early days; the pediatrician said I did not need to give tea to the baby and prescribed a medicine, but my mother claimed that the baby would get better faster with the tea [...] (A1)

[...] my mother came to help me, but she was always telling me that I didn’t have plenty of milk, that my baby was crying because he was hungry, and told me to introduce formula milk to complement breast milk, as she had done. [...] (A12)

A study conducted in the city of Goiânia found that in the early and late postnatal period women are greatly influenced by family habits and beliefs, which is maximized by the scarce information provided by health professionals. These findings highlight the need for the implementation of a continuous and better planned educational process based on the participation of all the parties, from pregnancy until the late postnatal period, in order to prepare these women to become confident and with the necessary knowledge to ensure appropriate breastfeeding to their infants (16).

The aforementioned study shows the interference of female family members who had previously experienced childbirth (grandmother, mother, sister, aunt) on feeding habits that may have a negative impact on postpartum women, with excessive dietary restrictions. The participants emphasized that adequate nutrition should start in the prenatal period to ensure better health conditions to mothers and infants, including breastfeeding.

In an integrative literature review on the practices suggested by grandmothers to support breastfeeding, the authors found that grandmothers recognize the importance of breastfeeding; they are a model to be followed; help in household chores and care; provide information and sometimes discourage breastfeeding. Finally, they concluded that the practices of support to breastfeeding of grandmothers are influenced by their own experiences and by their sociocultural context (17).

Weak or insufficient milk

Weak or insufficient mike were the most common explanations of women in the sample for early weaning of their infants early. One study indicated that weak milk is a cultural factor, and can be considered a myth, since it is known that most women have enough milk for their children. Such a perception, somewhat mistaken, can be related to lack of knowledge of the mothers on the importance of their milk, on how maternal milk is produced and because they related infant crying to lack of food, which is not always true (18).

[...] he was suckling all the time, was never satisfied [...](A1)

[...] my baby cried a lot and didn’t want to leave the breast; I didn’t know the reason [...](A3)

[...] I squeezed my nipples but it discharged a watery milk [...] (A9)

[...] When my baby got bigger, my milk was not enough [...](A11)

It should be noted that mothers sometimes do not want to breastfeed and explain breasfeeding interruption by claiming that their milk is weak or that they have insufficient milk supply. This happens because these mothers feel the need to explain to the others and also to themselves (to feel good) why they are not breastfeeding. In the aforementioned study, only 4.3% of the women admitted they weaned their babies without reason (18).

Despite the scientific evidence supporting the real benefits of maternal milk over other foods and the biological conditions of women favorable to the production of sufficient milk, the claim of insufficient milk supply was the most relevant for breastfeeding interruption, followed by breast refusal Both situations are indicated as reasons for the introduction or maintenance of formula milk (19).

Mothers working outside the home

The participants claimed that work outside the home was an aggravating factor for breastfeeding discontinuation because the spent a lot of time away from the children, in spite of their reduced working hours and the intervals for breastfeeding observed by the companies. It was found that all the mothers/women introduced artificial/formula milk in the diets of their infants. Pumping breast milk, although recommended, was little used and little mentioned during the pregnancy and postpartum period.

“... I had to work; the nurse instructed me to pump the milk, but it is not practical...” (A6).

“... When I returned to work exclusive breastfeeding was no longer possible, but I continued to breast feed until my daughter refused.it...” (A19).

Mothers who work outside the home are at a potential risk for early breastfeeding discontinuation, and deserve special attention of health professionals, through individualized and systematic support to the mother-child dyad (20).

The separation of mother-child dyad due to return to work is a risk factor for early weaning, and the lack of information on pumping and adequate storage of maternal milk, a topic not often discussed during the prenatal period, is an aggravating factors. (16).

The informative leaflet for working women who are breastfeeding developed by the Brazilian Ministry of Health should be more widely disseminated to provide them with the necessary guidance on how to ensure the enforcement of their labor rights (21).

FINAL CONSIDERATIONS

Breastfeeding is undoubtedly the best food for the infant and is considered the first healthy lifestyle with beneficial effects that may extend well into adulthood. However, this practice is not fully instinctive in humans, and sometimes women need advice from health professionals regarding the duration of breastfeeding, among other important aspects.

The data collected in this study provided knowledge on the experience of some women regarding breastfeeding, difficulties and complications that contributed to early weaning. The study also provided information on the role of the nursing team regarding the general care throughout pregnancy and childbirth and in the follow-up until the sixth month of life of the children.

Concerning nursing team care some failures were identified: they involved noncompliance with basic guidance during the process, as well as the methods used to deliver care practices: e.g. use of a technicist approach, strict observation of institutional standards or even imposing breastfeeding to women by making them feel guilty for not performing the practice correctly.

Nursing care must go beyond the threshold methods, by generating a new care model produced by nurses committed to the improvement of care that can be replicated in new publications; this new model should incorporate the unique needs of each woman/mother, contemplating their previous history and their momentary desires and their insufficient knowledge on the issue.

Therefore, emphasis should be given on the training of health professionals to seek greater involvement and adherence to new cultural values that support the practice of breastfeeding. Since breastfeeding is not a merely biological instinct and must be learnt by women, failures may occur. That is why nursing professionals should be prepared to identify the women at greater risk for breastfeeding discontinuation and help them overcome these difficulties.

One limitation of the study is related to the sample size: few mothers were interviewed and only in a small area of the city of Cáceres - MT. Thus, the measurement of the variables that influence the efficacy of breastfeeding up to six months of life of the children was not possible, limiting the generalizability of the findings. Nevertheless, this information should be disclosed to encourage other studies in other locations, which may contribute to the improvement of breastfeeding practice.

One contribution of this study is that nursing professionals in basic care play a key role in the guidance of mothers during prenatal and postpartum periods, once they can identify at an early stage the factors described in this study that directly interfere with continuous breastfeeding. In addition, the more training nursing professionals get, the lower the chances of these women feeling helpless and the greater their chances of feeling empowered. Well-trained health professionals will be more attentive to women’s needs at every stage of the pregnancy and childbirth cycle, contributing to the success of breastfeeding, reducing infant morbidity and mortality rates and adhering to the recommendations of Millennium Development Goals 4 and 5.

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Received: June 29, 2015; Accepted: December 03, 2015

Author’s address: Carolina Sampaio de Oliveira. Rua João Albuquerque nº 350 78200-000 Cáceres – MT. E-mail: carolinasampaio@unemat.br

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