Factors associated with the maintenance of exclusive breastfeeding in the late postpartum

Factores asociados al mantenimiento de la lactancia exclusiva en el posparto tardío

Abstract

Objective:

To identify the factors associated with the maintenance of exclusive breastfeeding and to verify the justification for the introduction of other liquids in the late postpartum of mothers and children attended by a breastfeeding consultant.

Method:

A non-comparative prospective cohort, conducted with 150 mothers and children. Data was collected at rooming-in 15 and 30 days after birth and analyzed by univariate analysis and multivariate regression.

Results:

The reasons for introducing water, tea, and breast milk substitutes were the following: thirst, abdominal cramps, and infant crying, respectively. Vaginal delivery, not using a pacifier or bottle and seeking professional help after discharge were associated with the exclusivity of late postpartum breastfeeding.

Conclusion:

The introduction of a professional breastfeeding consultant is of significant importance in the rise of exclusive breastfeeding rates.

Keywords:
Breast feeding; Maternal-child nursing; Consultants; Postpartum period

Resumen

Objetivo:

Identificar los factores asociados con el mantenimiento de la lactancia materna exclusiva y verificar la justificación para la introducción de otros líquidos en el posparto tardío de madres y niños atendidos por un consultor en lactancia materna.

Método:

Cohorte prospectiva no comparativa realizada con 150 madres y niños. Los datos se recolectaron en el alojamiento conjunto 15 y 30 días después del nacimiento y se analizaron mediante análisis univariado y regresión multivariada.

Resultados:

Las razones para introducir agua, té y sustitutos de la leche materna fueron las siguientes: sed, calambres abdominales y llanto infantil, respectivamente. El parto vaginal, no usar un chupete o biberón y buscar ayuda profesional después del alta se asociaron con la exclusividad de la lactancia durante el posparto tardío.

Conclusión:

La incorporación de un consultor profesional en lactancia materna es de suma importancia en el aumento de las tasas de lactancia materna exclusiva.

Palabras clave:
Lactancia materna; Enfermería materno-infantil; Consultores; Periodo posparto

Resumo

Objetivo:

Identificar os fatores associados a manutenção do aleitamento materno exclusivo e verificar a justificativa para introdução de outros líquidos no pós-parto tardio, de mães e crianças atendidas por consultor em aleitamento materno.

Método:

Coorte prospectiva não comparada, realizado com 150 com mães e crianças. Os dados foram coletados no alojamento conjunto, aos 15 e 30 dias após o nascimento e analisados por meio de análise univariada e regressão multivariada.

Resultados:

Os motivos para a introdução de água, chá, e substitutos do leite materno foram respectivamente: sede, cólicas abdominais e choro da criança. O parto vaginal, a não utilização de chupeta ou mamadeira e a busca por ajuda profissional após a alta se associaram a exclusividade da amamentação no pós-parto tardio.

Conclusão:

A inserção de um profissional consultor em aleitamento materno tem relevante importância na ascensão das taxas de aleitamento materno exclusivo.

Palavras-chave:
Aleitamento materno; Enfermagem materno-infantil; Consultores; Período pós-parto

INTRODUCTION

The practice of breastfeeding has suffered various social and cultural influences due to the times and customs of each historical moment; however, the concrete establishment of its benefits has been found in scientific circles for over 50 years⁽¹⁾.

Although the privileges associated with breastfeeding are unquestionable, whether for the nursing mother or infant⁽²⁾, its interruption before the recommended period is still frequent. In view of this, the qualification to act in face of this demand is necessary and rising, as the Lactation Consultant ⁽³⁾ professional.

Created in the 1980s, to receive the title of Lactation Consultant, the professional must be accredited by the International Board of Certified Lactation Consultants (IBCLC), the only internationally recognized professional lactation certification body to provide safe and evidence-based care for breastfeeding women and their babies⁽³⁾.

Studies in Italy and the Netherlands, as well as a systematic review and meta-analysis, have already shown the superiority of a consultant's role in improving breastfeeding outcomes^(4-6).

Based on the prerogatives of benefits combined with the performance of this professional, this study assumes that the performance of breastfeeding (BF) consultants in the immediate postpartum favors the establishment, as well as the exclusivity, of breastfeeding after discharge in the late postpartum, the most vulnerable phase due to insecurity and lack of knowledge in the management of the difficulties related to lactation⁽⁷⁾.

This study aims to identify the factors associated with the maintenance of exclusive breastfeeding (EBF) and to verify the justification for the introduction of other liquids in the late postpartum of mothers and children attended by BF consultant.

METHOD

This study is part of the project entitled: “Breastfeeding Patterns of Children Attended by a Breastfeeding Advisory Team”. The data used came from the follow-up of the participants during the 30 days postpartum.

This is a non-comparative prospective cohort study, conducted with mothers and children in the immediate postpartum period, hospitalized in a rooming-in modality and attended by a BF consultant at the Hospital de Clinicas de Porto Alegre/RS.

The institution's BF consultancy team consists of a nutritionist and two nurses, one of whom is accredited by the IBCLC. The consultations are directed to cases in which difficulties in the effective establishment of breastfeeding are observed, which may become a barrier to the permanence of EBF.

Mothers and children in a rooming-in modality who had been assisted by a BF consultant residing in Porto Alegre or in the metropolitan region, who provided their telephone number, with full-term children (Capurro ≥ 37 weeks) with a birth weight ≥ 2,500 g were included. Mothers with twin children who had a permanent or temporary indication for breastfeeding or who had to be separated after starting breastfeeding were excluded.

The period of inclusion of participants was August 2016 to January 2017, with follow-up by telephone until March of the respective year. Information was collected for this research in three moments: in person at the Obstetric Inpatient Unit (OIU), the woman being interviewed after the first 24 hours of the child's birth and after receiving care from a BF consultant, and by telephone 15 and 30 days after birth, with a maximum period for the application of the questionnaire of two days after the child reaches the established age for follow-up. For data collection two questionnaires were used, previously elaborated by the researchers and submitted to a pilot test. The first questionnaire, completed in person at the bedside in the OIU, contained sociodemographic and maternal variables related to current pregnancy, prenatal care and type of delivery. The questionnaire applied 15 and 30 days after birth, via telephone contact, addressed issues related to maternal habits, problems with breastfeeding and liquid introduction to the child.

The minimum sample size calculated was 150 individuals, using the WinPEPI software, version 11.43. A mean percentage of 60%⁽⁸⁾ of EBF was considered at the end of the first month and a minimum risk rate of 1.48⁽⁹⁾, with a power of 80%, significance level of 5% and estimated loss of 20% over the follow-up.

The collected data was tabulated and evaluated by pairs to correct any typing errors and then analyzed in the SPSS (Statistical Package for the Social Sciences) statistical software, version 20.0. First, descriptive statistics were performed for the numerical variables through measures of central tendency and for those of categorical nature proportions.

The statistical calculation performed to test the differences between the before and the after measurements was the McNemar's test (non-parametric). To study the association between the independent variables and the study outcome, logistic regression of the variables at each level of determination was performed using Pearson's chi-square test. For the association among the variables, Odds Ratio was used. The outlierswere excluded and the multicollinearity test was evaluated according to the parameters ofToleranceand VIF (Variance Inflation Factors).

The variables that were statistically significant in the univariate analysis (p<0.20) were selected for multivariate analysis using the non-conditional forward stepwise(likelihood ratio) method.

For all inferential statistical tests, the significance level p<0.05 and the R values²of Nagelkerke were used. The quality of fit was assessed by the Hosmer-Lemeshow test. To verify the normality of the data, the Kolmogorov-Smirnov test was used.

Participants signed a two-way Free Informed Consent Form (FICF). The project to which the present study is linked was approved by the Research Ethics Committee of the Hospital de Clinicas de Porto Alegre, under opinion No. 1,569,774/2016 and CAAE 55433516.1.0000.5327 on 6/1/2016.

RESULTS

The study included 150 mothers and children for follow-up within 30 days postpartum. Total losses during follow-up were 29, 10 at 15 days and 19 at 30 days. At the end of the follow-up, 52.5% of the individuals were on EBF and 13 children had been weaned, three before the first 15 days.

Regarding the profile of the individuals studied, the characteristics of the sample are shown in Table 1.

Table 1
Characteristics of mothers in rooming-in attended by BF consultants. Porto Alegre, RS, Brazil, 2016/2017

Variables	n = 150
Maternal age ≥ 20 years old	122	(81.3%)
Maternal schooling ≥ 8 years	121	(80.7%)
Self-reported Caucasian mother	93	(62.0%)
Having a partner	130	(86.7%)
Performed prenatal care	148	(98.7%)
No. of prenatal consultations ≥ 8ǂ	110	(73.3%)
Oriented on BF in prenatal careǂ	44	(29.7%)
Smoking during pregnancy	21	(14.0%)
Drug use during pregnancy	3	(2.0%)
Vaginal delivery	88	(58.7%)
Family income (minimum wages)ǂǂ	2.2	(1.3-3.4)*
Time of BF in previous child (months)¶	3	(0-11)*

• Source: Research data, 2016/2017.
• ǂ Excluding those who did not have prenatal care (n=2); * Result expressed as median and interquartile range; ǂǂ Excluding those who could not inform (n=22); ¶ Excluding primigravidas (n=107)

The reasons for weaning reported by the mothers were low milk production (46.2%), difficulty in the breastfeeding technique (38.4%) and breast refusal (15.4%).

Over the 30 days, 6.8% of the children received water, 21.2% tea, and the introduction of breast milk substitutes was reported by 38.1% of the mothers. The prevalent reason reported for the introduction of each liquid was thirst (3.4%), colic (12.7%) and NB crying associated with perception of weak breast milk (12.7%), respectively. These liquids were offered by 91.1% of the mothers in nursing bottles.

The comparison between follow-up variables 15 and 30 days after delivery is described in Table 2.

Table 2
Comparison between study variables and postpartum follow-up. Porto Alegre, RS, Brazil, 2016/2017

Variables	15 days	30 days	p-value
	n (%)	n (%)
Exclusive breastfeeding	96 (64)	62 (41.3)	0.000
Cross-breastfeeding	4 (2.7)	9 (6)	0.063
Domestic and NB assistance	124 (82.7)	97 (64.7)	0.115
Nipple/Nursing bottle use	74 (49.3)	71 (47.3)	0.019
Cup/Spoon use	8 (5.3)	5 (3.3)	0.125
Breast pain	75 (50)	44 (29.3)	0.018
Breast cracks	65 (43.3)	22 (14.7)	0.000
Full breast	91 (60.7)	56 (37.3)	0.008
Breast erythema	23 (15.3)	15 (10)	0.503
Breast fever	14 (9.3)	13 (8.7)	0.832
Nipple anatomy	11 (7.3)	5 (3.3)	0.289
Difficulty in the technique	20 (13.3)	14 (9.3)	0.791
Low production	11 (7.3)	9 (6)	0.754
Looking for professional help in BF	24 (16)	10 (6.7)	0.064

• Source: Research data, 2016/2017.

The proportion of EBF maintenance was lower at 30 days postpartum compared to the first fifteen initial days, and this difference was significant. On the other hand, there was a significant reduction in the proportion of nipple/nursing bottle use, breast pain, cracks and full breasts.

The factors associated with EBF according to demographic, economic and reproductive characteristics are described in Table 3. In this first analysis, the type of delivery and prenatal guidance on BF were associated with the outcome of the study.

Table 3
Univariate analysis of factors associated with EBF according to sociodemographic, economic and reproductive factors. Porto Alegre, RS, Brazil, 2016/2017

Variables	Exclusive breastfeeding
	Yes (n=62)	No (n=46)	OR (gross)	p-value
Age group
≥ 20 years old	51 (47.2)	37 (34.3)	1	0.501
< 20 years old	11 (10.2)	9 (8.3)	1.12
Parity				0.232
Primiparous	36 (33.6)	23 (21.5)	0.69
Multiparous	25 (23.4)	23 (21.5)	1
Income				0.252
≥ 4 wages	10 (10.9)	5 (5.4)	1
< 4 wages	41 (44.6)	36 (39.1)	1.75
Schooling (years)				0.583
≥ 8 years old	50 (46.3)	37 (34.3)	1
< 8 years	12 (11.1)	9 (8.3)	1.10
Type of delivery				0.044
Vaginal	41 (38)	22 (20.4)	0.47
Cesarean section	21 (19.4)	24 (22.2)	1
Episiotomy				0.108
Yes	26 (41.3)	18 (28.6)	1
No	15 (23.8)	4 (6.3)	0.38
Cohabitation partner				0.520
Yes	49 (51)	39 (40.6)	0.79
No	4 (4.2)	4 (4.2)	1
Smoking				0.504
Yes	7 (6.5)	6 (5.6)
No	55 (50.9)	40 (37)
No. of prenatal consultations				0.395
> 8 consultations	49 (47.6)	32 (31.1)	1
≤ 8 consultations	11 (12.7)	10 (9.7)	1.27
PN guidance on BF				0.023
Yes	24 (22.4)	9 (8.4)	1
No	37 (34.6)	37 (34.6)	2.66
Previous history of failure with BF				0.613
Yes	53 (49.5)	40 (37.4)	1.10
No	8 (7.5)	6 (5.6)	1

• Source: Research data, 2016/2017.

Table 4 shows the factors associated with EBF according to maternal habits related to breastfeeding. Not using a nipple/nursing bottle and not presenting cracks, as well as the use of a cup/spoon and seeking professional help in BF were associated with the outcome.

Table 4
Univariate analysis of factors associated with EBF according to maternal habits related to breastfeeding. Porto Alegre, RS, Brazil, 2016/2017

Variables	Exclusive breastfeeding
	Yes (n=62)	No (n=46)	OR (gross)	p-value
Nipple/Nursing bottle use				0.000
Yes	20 (18.5)	41 (38)	17.22
No	42 (38.9)	5 (4.6)	1
Breast pain				0.207
Yes	21 (19.4)	20 (18.5)	1.50
No	41 (38)	26 (24.1)	1
Breast cracks				0.023
Yes	8 (7.4)	14 (13)	2.95
No	54 (50)	32 (29.6)	1
Full breast				0.555
Yes	30 (27.8)	22 (20.4)	1
No	32 (29.6)	34 (22.2)	0.97
Difficulty in the technique				0.202
Yes	4 (3.7)	6 (5.6)	2.17
No	58 (53.7)	40 (37)	1
Nipple anatomy				0.389
Yes	1 (0.9)	2 (1.9)	2.77
No	61 (56.5)	44 (40.7)	1
Cup/Spoon use				0.000
Yes	24 (22.2)	4 (3.7)	1
No	38 (35.2)	42 (38.9)	6.63
Domestic and NB assistance				0.417
Yes	49 (45.4)	38 (35.2)	0.79
No	13 (12)	8 (7.4)	1
Seeking professional help in BF after discharge				0.010
Yes	1 (0.9)	7 (6.5)	1
No	61 (56.5)	39 (36.1)	10.94

• Source: Research data, 2016/2017.

Table 5 shows the final logistic regression of the significant variables. Having a normal delivery had a 4.18 times greater chance of sustaining EBF at the end of 30 days postpartum compared to women who had cesarean deliveries. Similarly, not using a nipple/nursing bottle in this study presented a 23.08-fold chance of EBF maintenance. Finally, seeking professional help with BF after discharge acted as a protective factor for maintaining EBF.

Table 5
Final multivariate logistic regression of factors associated with EBF. Porto Alegre, RS, Brazil, 2016/2017

Variables	Adjusted OR	CI 95%	p-value
Nipple/Nursing bottle use	23.08	5.86 - 90.92	0.000
Cup/Spoon use	1.74	0.40 - 7.53	0.457
Breast cracks	1.03	0.26 - 4.05	0.963
Seeking professional help in BF after discharge	0.05	0.00 - 0.92	0.044
PN guidance on BF	0.56	0.17 - 1.87	0.353
Type of delivery	4.18	1.27 - 13.71	0.018

• Source: Research data, 2016/2017.

DISCUSSION

The data showed that the maintenance of EBF occurred in more than half of the subjects studied. A research conducted in Ceará found lower results in the same period (39.2%)⁽¹⁰⁾. It can be inferred from this that, although the subjects studied present some previous difficulty related to BF, the support offered by breastfeeding consultancy acted in solving this demand, increasing the proportion of mothers and children in EBF. A quasi-experiment conducted in the Netherlands corroborates the assertion that the intervention by individuals trained by the IBCLC is effective in increasing the duration and exclusivity of breastfeeding, as well as in delaying weaning⁽⁵⁾.

The introduction of water was justified by the mothers by the feeling that the child was feeling thirsty. However, many mothers are unaware of the high presence of water contained in the so-called previous milk, which is offered at the beginning of breastfeeding⁽¹¹⁾; this makes the offer of liquid to the child completely independent of the seasonal period.

Most of the times, tea was introduced in an attempt to calm the child's colic. A study conducted in Maranhão also demonstrated the use of tea for the same purpose⁽¹²⁾.

The introduction of breast milk substitutes was justified by the fact that the child cries from hunger, associating to this the perception of breast milk being weak. A study conducted in São Paulo was in line with this finding, since 47% of the participants believe they have weak milk, motivated by the child's crying⁽¹³⁾.

The mothers who introduced some liquid to their children did so with the aid of a nursing bottle in most cases. The harm associated with the use of a nursing bottle and a pacifier regarding the maintenance of EBF has already been described at national⁽¹⁴⁾ and international⁽¹⁵⁾ levels. In this research, the non-use of such artifacts presented a 23.08 times greater chance of maintaining EBF. Early introduction of artificial nipples, such as a pacifier and a nursing bottle, can contribute to the confusion of nipples by the child, also affecting grip and sucking, determining factors for successful breastfeeding⁽¹⁴⁾.

Having a normal delivery had a 4.18 times greater chance of sustaining EBF at the end of 30 days postpartum compared to women who had cesarean deliveries. The mode of delivery is related to the early onset of breastfeeding, as it should occur immediately after birth, as recommended by Step 4 of the Baby Friendly Hospital Initiative, in order, among other reasons, to foster bonding, increasing the duration of breastfeeding⁽¹⁴⁾. A survey conducted in Saudi Arabia found that mothers who had a cesarean delivery were about 1.42 times more likely not to breastfeed in the first hour of life when compared to mothers who had a vaginal delivery⁽¹⁶⁾.

The search for a professional for breastfeeding assistance after discharge acted as a protective factor for the maintenance of EBF. A study conducted in Turkey was in line with this result⁽¹⁵⁾. Late postpartum is sometimes less evidenced, taking into account the actions to strengthen BF in the prenatal and in the immediate postpartum. However, it is considered a vulnerable period, and research has already pointed to the need for continued breastfeeding care and counseling^(17-18).

Accordingly, the Ministry of Health has implemented the First Week Integral Health as a strategy, an action that aims to provide integral and multi-professional care to the postpartum woman and to the child in the first week after delivery. It can be performed through home visits aimed at identifying risk signs, providing guidance and encouraging BF. This strategy has great potential in improving the quality of life of the mother and of the child, it assists in maternal empowerment and delays the introduction of breast milk substitutes⁽¹⁹⁾.

It is noteworthy that, despite the BF advice offered during hospitalization, the subjects referred to this service already had some degree of difficulty with BF, needing more attention and supporting the search for help also after hospital discharge which, according to the findings of this study, seems to favor EBF.

CONCLUSION

Vaginal delivery, not using a pacifier or a nursing bottle and seeking professional help after discharge were associated with the maintenance of EBF in the late postpartum. The alleged reasons for introducing water, tea, and breast milk substitutes were thirst, abdominal cramps, and infant crying, respectively. Such reasons, although already described in other studies, do not represent situations in which there is a concrete indication of the introduction of such liquids.

Despite the assumption that institutions accredited as Child Friendly have professionals engaged in the cause of BF, the insertion of a professional breastfeeding consultant who acts exclusively in response to this demand is of significant importance, especially regarding the rise in EBF rates, providing the proven benefits of breastfeeding to the subjects involved.

Further studies are suggested, especially at the national level, which cover the performance of this professional and the relevance of their inclusion in the team, providing greater visibility and instigating future investments of the part of health services to enjoy the benefits provided by their work.

Acknowledgments:

To the nurses Cléa Machado de Carvalho and Marcia Knoener, who enabled this research through the work done in the breastfeeding consultancy.

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  Lucena DBA, Guedes ATA, Cruz TMAV, Santos NCCB, Collet N, Reichert APS. First week of integral health for the newborn: nursing actions of the Family Health Strategy. Rev Gaúcha Enferm. 2018;39:e2017-0068. doi: https://doi.org/10.1590/1983-1447.2018.2017-0068
  » https://doi.org/10.1590/1983-1447.2018.2017-0068

Publication Dates

• Publication in this collection
  25 Nov 2019
• Date of issue
  2020

History

• Received
  06 Mar 2019
• Accepted
  13 Aug 2019