Motivations for breastfeeding prolongation

Abstract

Objective

Our aim was to explain the motivational structure that accompanies the decision by mothers who breastfeed for more than two years.

Methods

Qualitative study in urban and rural women aged 20 to 44 years in the communes of Temuco and Padre Las Casas, Chile. The data collection technique was an in-depth interview. The inductive method of analysis based on Grounded Theory enabled a constant comparative process until the theoretical saturation of the data and the 3 coding stages: open, axial and selective.

Results

Eight women agreed to participate. Four dimensions were identified: life experience, maternal self-analysis, stimuli from the mother herself and from the child, and social and cultural stimuli, which underlie the motivational structure that accompanies the decision by mothers to continue breastfeeding for longer than two years. In childhood the motivations are mainly intrinsic (family culture of breastfeeding) and in adulthood there are intrinsic motivations (maternal feelings, mother’s internal stimuli) and transcendent motivations (stimuli from the child), with these being reinforced by stimuli originating from the social and cultural milieu (family surroundings).

Conclusion

For a woman, childhood is the motivational period par excellence to integrate breastfeeding as the best option for feeding her children. In adulthood, the transcendent motivation is consolidated in the first stage of child-rearing, affording greater motivational quality to the prolongation of breastfeeding. Public policies must focus their actions on these stages of a woman’s life to improve breastfeeding indicators.

Breastfeeding; Child-mother relations; Feeding behavior

Resumo

Objetivo

explicar a estrutura motivacional que acompanha a decisão das mães que amamentam por mais de dois anos.

Métodos

estudo qualitativo em mulheres de zonas urbanas e rurais, entre e 20 e 44 anos de idade, nas comunas de Temuco e Padre Las Casas, Chile. A técnica empregada para coleta de dados foi a de entrevista em profundidade. O método indutivo de análise, baseado na Teoria Fundamentada em Dados ( Grounded Theory ), possibilitou um processo comparativo constante até alcançar a saturação teórica dos dados e as três etapas de codificação: aberta, axial e seletiva.

Resultados

oito mulheres concordaram em participar. Foram identificadas quatro dimensões: experiência de vida, autoanálise materna, estímulos da própria mãe e do filho e estímulos sociais e culturais, que estão subjacentes à estrutura motivacional que acompanha a decisão das mães de continuarem amamentando por mais de dois anos. Na infância, as motivações são principalmente intrínsecas (cultura familiar da amamentação). Na idade adulta, há motivações intrínsecas (sentimentos maternos, estímulos internos da mãe) e motivações transcendentes (estímulos da criança), que são reforçadas por estímulos originários do meio social e cultural (ambiente familiar).

Conclusão

para as mulheres, a infância é o período motivacional por excelência para integrar a amamentação como a melhor opção para alimentar seus filhos. Na idade adulta, a motivação transcendente se consolida no primeiro estágio da educação dos filhos e proporciona maior qualidade motivacional ao prolongamento do aleitamento materno. As políticas públicas devem focar suas ações nessas etapas da vida da mulher para melhorar os indicadores de amamentação.

Aleitamento materno; Relações mãe-filho; Comportamento alimentar

Resumen

Objetivo

Explicar la estructura motivacional que acompaña la decisión de madres que amamantan durante más de dos años.

Métodos

Estudio cualitativo en mujeres de zonas urbanas y rurales, entre 20 y 44 años de edad, en las comunas de Temuco y Padre Las Casas, Chile. La técnica empleada para la recolección de datos fue la de entrevistas en profundidad. El método inductivo de análisis, basado en la teoría fundamentada en datos ( Grounded Theory ), posibilitó un proceso comparativo constante hasta alcanzar la saturación teórica de los datos y las tres etapas de codificación: abierta, axial y selectiva.

Resultados

Ocho mujeres aceptaron participar. Se identificaron cuatro dimensiones: experiencia de vida, autoanálisis materno, estímulos de la propia madre y del hijo y estímulos sociales y culturales, que están por detrás de la estructura motivacional que acompaña la decisión de las madres de continuar amamantando durante más de dos años. En la infancia, las motivaciones son principalmente intrínsecas (cultura familiar de la lactancia). En la edad adulta, hay motivaciones intrínsecas (sentimientos maternos, estímulos internos de la madre) y motivaciones trascendentes (estímulos del niño), que se refuerzan con estímulos originarios del medio social y cultural (ambiente familiar).

Conclusión

Para las mujeres, la infancia es el período motivacional por excelencia para integrar la lactancia como la mejor opción para alimentar a sus hijos. En la edad adulta, la motivación trascendente se consolida en el primer nivel de la educación de los hijos y proporciona mayor calidad motivacional para la prolongación de la lactancia materna. Las políticas públicas deben centralizar sus acciones en estas etapas de la vida de la mujer para mejorar los indicadores de lactancia.

Lactancia materna; Relaciones madre-hijo; Conducta alimentaria

Introduction

Breast milk changes its composition over time and adapts to the infant’s requirements: the more prolonged the breastfeeding, the greater the benefits to mother and child.( ¹ , ² )However, it is increasingly less feasible to find dyads with prolonged periods of breastfeeding.( ³ )There is no agreed-upon definition regarding prolonged breastfeeding, but it is considered to be over the minimum period recommended by the World Health Organization (WHO), i.e., two years of age.( ⁴ )Currently, around 43% of children are breastfed exclusively to 6 months in different parts of the world.( ⁵ )In Latin America and the Caribbean the prevalence is only 32%.( ⁶ )In Chile, the prevalence of exclusive breastfeeding to the sixth month is 53% and in the Region of La Araucanía, in the center-south zone of the country, it is more than 60%, making it one of the highest rates in the country.( ⁷ )This number is influenced by the large indigenous (Mapuche) population present in the region, who frequently nurse until two to three years of age.( ⁸ )Breastfeeding data beyond two years in the general population are not known.

In Chile, all current efforts are aimed at improving breastfeeding indicators to the sixth month, but not its prolongation over time, although the evidence that shows the benefits of prolonged breastfeeding is growing.( ¹ , ³ , ⁹ , ¹⁰ )

There is significant evidence as to why mothers stop nursing;( ¹¹ , ¹² )however, few studies show the motivations to continue nursing beyond the culturally accepted times. The mothers’ motivations will ultimately define the duration of breastfeeding. This decision is influenced by different types of factors and with highly varied experiences. According to the theory of self-determination, there are motivations that move people to act according to their own values and self-satisfaction, without this leading to external compensation (intrinsic motivation), and motivations brought about by external stimuli, which are associated with some type of material reward or social recognition (extrinsic motivation). Both motivations regulate decision-making; however, it is recognized that the possibility of internalizing and integrating extrinsically motivated activities as one’s own also promotes behavior towards fulfilling a goal.( ¹³ )Finally, the transcendent motivation that emerges from the organizational area can be extrapolated to individual forces that lead people to meet objectives that go beyond self-actualization or possible rewards, such as the well-being of others, in this case, of the son or daughter.( ¹⁴ )Most breastfeeding campaigns or adherence strategies are based on motivating health care personnel to promote breastfeeding, but there is no clear policy to employ the motivations of the woman herself because there is little evidence of what these are. This knowledge is relevant to its incorporation in the design and implementation of strategies to prolong breastfeeding and with it the benefits to mothers and children.( ³ , ¹⁵ )

The aim of this study was to understand the motivational structure that accompanies the decision by urban and rural mothers in the Region of La Araucanía, Chile, to continue breastfeeding beyond two years.

Methods

A qualitative study with theoretical sampling( ¹⁶ , ¹⁷ )was conducted during second semester of 2016 among urban and rural women aged 20 to 44 years who attended their health check-ups in the public service or who belonged to a non-governmental organization named Trawün Domo (social organization focused on the protection of the dyad in the process of motherhood and parenting) located in the communes of Temuco and Padre Las Casas in the Region of La Araucanía, Chile. The sample was shaped until data saturation had been achieved. The requirement was to have nursed their last child for more than two years and to have signed an informed consent. The only exclusion criterion was cognitive disability, reading and writing was not necessary because the data collection technique was oral. Such sampling is the most appropriate to explore new areas of knowledge and privileges the phenomenon of study and therefore those people who live the experience and can best contribute to the developing content. This type of sampling maximizes the opportunities to develop and discover variations between the concepts and to make the categories denser in terms of their properties and dimensions.( ¹⁷ )It is worth noting that the women with these characteristics are few and the real prevalence of prolonged breastfeeding is not known.

The data collection technique was the face to face in-depth interview. The main questions that guided the interview were constructed based on the objectives proposed for the research.( ¹⁷ )The questions were tested in three women of different cultural and socio-economic level to assess understanding and objectivity of the answers. Questions that led to errors in interpretation were modified and re-formulated until they were fully understandable. The principal questions were: “In your childhood and adolescence, do you remember if your mother breastfed you or any of your siblings?”; “Any other experience in this regard?”; “What did that mean to you and how has that influenced your actual decision to prolong breastfeeding?” “As an adult, what other experiences have you had?”; “How did they influence your decisions?”; “During your pregnancy, did you receive information about breastfeeding? From whom?”; “How has this information influenced your decision to prolong breastfeeding?”; “How was the process of delivery and post-partum in relation to breastfeeding?”; “How did those experiences influence your decision?”; “During your baby´s first 2 years, what was your experience in relation to nursing, health care, interaction with family and your environment?”; “Of all these experiences, what do you believe most influenced your decision to breastfeed and prolong lactation and why?”; “What has it meant for you to continue breastfeeding until today?”. These questions were followed by others, depending on the answers, which allowed to deepen the development of the categories. The interviews were conducted by the principal researcher in different places depending on the preference of the participants: clinical room of urban or rural health center, in their homes or a university meeting room. Each interview lasted between 45 and 60 minutes. All participants were interviewed with their child present. The narratives were audio recorded and transcribed literally. The inductive method of analysis based on Grounded Theory enabled a constant comparative process until the theoretical saturation of the data and the 3 stages of coding: open, axial and selective.( ¹⁸ , ¹⁹ )From this process the different categories were constructed, which were interrelated to construct the explanatory framework of the motivations for the prolongation of breastfeeding. The qualitative analysis was assisted by the Atlas.ti 7 computer package. The results were discussed with the participants, confirming the veracity of the accounts. This study was approved by the Scientific Ethics Committee of the Universidad de La Frontera (N° 236/2015).

Results

Of the 8 women who agreed to participate, only one had less than 8 years of formal education, one worked outside the home and seven of them had a partner. Four resided in an urban area, two belonged to the ethnic Mapuche group and the time of breastfeeding ranged between 2 and 7 years. Characteristics of each participant are shown in table 1 .

Table 1
Characteristics of the participants

Participants	Age	Educational level	Residency	Organization	Mapuche	Marital status	Months of lactation
1	25	University	Urban	Trawun Domo	No	Single	26
2	20	High school	Urban	Health centre	No	Married	30
3*	37	High school	Urban	Trawun Domo	No	Married	30
4	36	High school	Urban	Trawun Domo	No	Married	28
5	37	Elementary	Rural	Health centre	Yes	Married	34
6	44	High school	Rural	Health centre	Yes	Married	84
7	37	High school	Rural	Health centre	No	Married	35
8	26	University	Rural	Health centre	No	Married	40

• *Worked outside the home

Four interrelated dimensions were identified to compose the motivation to prolong breastfeeding: 1) life experiences; 2) positive feelings/emotions; 3) stimuli from the mother herself and from the child; 4) social and cultural encouragement. First, an analysis was performed separately of the accounts of the women from the ethnic Mapuche group; nevertheless, as no differentiating elements were found stemming from the cosmovision with respect to the motivations to prolong breastfeeding, the joint analysis was performed. In the dimension Life experiences, ideas were grouped to recognize the life stage at which the motivation to prolong breastfeeding occurred. During childhood the memory is revealed of having been breastfed for a prolonged period in her own childhood and coming from a family with a culture of prolonged breastfeeding. Some of the accounts that represent this category are described next:

“…yes, I have a big family, my grandmother gave birth to nine children, seven childbirths at home, on my mother’s I am the eldest and we are six, so I saw my mother nurse all my brothers and sisters, the one that follows after me nursed for four years…”

“…yes, the first that comes to mind was when I breastfed up to about 5 (years), until my younger brother started breastfeeding and then I said, like going back to that same scene but with my own child…”

In adolescence, the history of the family culture again stands out as important. However, in adulthood, the experiences of the prenatal, postpartum and postnatal stages emerged in relation to prolong breastfeeding and the history of having nursed a previous child for an extended period was highlighted. The most common accounts in this category were:

“…it’s not like I said beforehand that I was going to breastfeed, because there are mothers who have decided … when she (baby) was born, the first thing I felt was that she was hungry and it was instinct. And then I told my mother I would nurse up to a year… later I thought… let’s give it a little longer and in the end I decided when she is able, until she goes to pre-school to 4 or 3 years, until she wants, I’ll nurse her...”

In the dimension Positive feelings/emotions , mothers performed a self-analysis and the feelings that prolonged breastfeeding evokes in them and what compels them to continue are described; emotions and feelings such as happiness, nurturing, pride and completeness stand out, represented in the following accounts:

“…for me it is something spectacular, it means so many things that, I don’t think it has a name, personally I love it, I think I’m addicted to oxytocin (laughs), really addicted, but it’s true, nothing makes me as happy as knowing that I give the best of myself, the best that I can give of me, I give it…“

“I feel proud… and in addition I had them when I was older (laughter), then it never occurred to me to buy a can of formula… they never drank, I always had a lot of milk so I said I’m going to nurse until… as much as I can, although they told me off at home”

The dimension Stimuli from the mother herself and from the child reveals preferences and benefits that she perceives for herself. It is worth noting that the mother values the needs of the child over her own, but she also appreciates the comfort that she gains from nursing. Added to the stimuli from the child is the effect of the prolongation of breastfeeding on the child’s health and attachment. Some accounts that represent this dimension are:

“…more than anything I continue nursing because I was a single mother and I feel that she is the main thing for me …”

“…breast milk is very good for them, in the sense that it complements food, meaning vitamins, minerals, calcium, hydration, it isn’t just food and hydration, but there is also the affection in between, right? ”

“…for me it is much easier to nurse him, especially when we go out, instead of carrying a bottle around, the thermos with water, so it helps me too …”

The dimension social and cultural encouragement from the environment demonstrates how the family, community and health care personnel support the decision to prolong breastfeeding. Some accounts that describe this:

“…my husband, he watches us and he loves it. He supports me in everything, watches us and loves to see Pedro, our son, how he puts his head to nurse ...... and for the rest of the family, it’s something natural… it’s not an issue… an issue would be bottle feeding”

“My neighbors, for example, don’t say anything to me, it’s something normal for them. My mother-in-law told me that before it was common to breastfeed because it is a natural food, for that reason the children from before didn’t get sick like they do now because they breastfed”

“…the pediatrician told me to breastfeed, if the baby gets fed up, don’t stop …”

The motivation that accompanies the decision by urban and rural mothers whom breastfeed for more than two years may have its origins in their life experiences at the different stages of life. In childhood and adolescence there is an intrinsic motivation, triggering stimuli from the memories of having been breastfed for a prolonged period, and thus also of having belonged to families where breastfeeding was practiced naturally and spontaneously. This is the point of greatest relevance in their decision. In adulthood, intrinsic and transcendent motivations are produced at the prenatal, postpartum and postnatal stages. Social and cultural stimuli reinforce these motivations in all of these stages, with the one stemming from family environment being the most relevant aspect. The postnatal stage is when most of the stimuli are triggered that produce the motivation to prolong breastfeeding. During this stage, one’s internal stimuli (comfort and priorities of life) and the feelings and emotions (pride, nurturing, completeness, happiness) that breastfeeding arouses are part of intrinsic motivation, unlike the stimuli from the child that structure transcendent motivation. Both types of motivation reinforce and connect to other experiences in the adult stage to make the decision to prolong breastfeeding. All this constitutes the motivational conceptual framework for the prolongation of breastfeeding. Figure 1 shows the categories, subcategories and main codes and the interrelations between them that represent what was explained in advance. The numbers under each one reflect the times that these appear in the interviews and the times that are related to other concepts forming the categories.

Figure 1
Motivational estructure for prolonged breastfeeding

Discussion

Motivation as a hypothetical-theoretical construct that alludes to a complex process that causes a behavior has been studied widely in the areas of education and labor organizations,¹⁹ but not in the area of decision-making around aspects of child-rearing such as the prolongation of breastfeeding.

Among the women who are part of the ethnic Mapuche group, breastfeeding is culturally valued as a way of maintaining attachment and communication with the child, which is why it occurs naturally and spontaneously. The practices typical of this ethnic group continue to today, and some Mapuche children nurse until 6 or 7 years.( ⁸ )At present, this finding occurs with less frequency particularly in non-Mapuche women; therefore, it is difficult for these women to shape their motivation from childhood.

When the motivation to nurse for a prolonged period is developed in adulthood, particularly in the child-rearing stage, the history of a previous experience of prolonged breastfeeding is relevant. This is consistent with Gribble, who shows that 94% of the women who had breastfed before stated that the experience had had a positive effect on their current relation with breastfeeding.( ²⁴ )

Motivation in adulthood is reinforced by stimuli from the child (perception of a healthier child) and by the attachment established in the dyad. Some results of successful breastfeeding show mothers’ opinions similar to this;( ²⁵ , ²⁶ )however, results can also be found in which the mother’s perceptions are ambivalent, i.e., pleasant feelings and others not as much, generated by the loss of autonomy that accompanies prolonging the period.( ²⁷ )On the other hand, the comfort for the mothers (intrinsic motivation) tips the scale in favor of prolongation, which agrees with the study by Carrascoza et al., who highlight that mothers continue nursing out of the comfort and ease that this practice affords them when they go out in public with their children and they do not have to take utensils to feed them.( ²⁸ )

The positive feelings that allow them to describe themselves as self-fulfilled in their role as mother and as woman reinforce their decision to prolong breastfeeding and make them impervious to comments from their environment about weaning, associated with myths referring to the nutritional value of breast milk. None of them referred spontaneously to negative feelings, unlike what was reported by Newman and Williamson, where it is observed that most women told of perceiving social stigma due to nursing older children,( ²⁹ )probably due to cultural differences among countries.

Social and cultural stimuli strengthen and enhance intrinsic and transcendent motivations in adulthood. The husband or partner and grandmothers appear as important figures within the family environment, although there is evidence that grandmothers can be a negative influence, particularly in the first months of life, because they cause weaning and on some occasions stimulate the introduction of formula.( ³⁰ )On the other hand, there are stimuli stemming from health care professionals. Women receive support to breastfeed during pregnancy and until the first 6 months of the baby’s life, where indications are reinforced. From there on, the perception is of a decline in reinforcement and, to be frank, sometimes weaning is promoted. This is perceived as health care personnel lacking knowledge with respect to the benefits of the prolongation of breastfeeding. This is also described in other studies, where the mothers interviewed suggest greater preparation and information on the part of the health care professionals regarding the duration of breastfeeding.( ³¹ )

The motivation to nurse and to continue over time was internalized and integrated early on, deeply and incontrovertibly. As this manner of structuring motivation has been lost given that only 20% continue breastfeeding to one year of life,( ⁶ )this culture needs to be recreated in the family, health organizations and society, incorporating daily aspects of breastfeeding in toys and children’s games, in the contents of formal education and mass media early on in childhood.( ³² )If this were public policy, it would be a step forward and not at great cost to the state, which would enable the creation of a coherent cultural environment that supports mothers in breastfeeding and its duration.( ³³ , ³⁴ )Interventions from the health sector at the prenatal, postpartum and postnatal stages are particularly valuable where integration of the motivation in childhood is lacking.

A limitation of this study was the number of participants, given the difficulty of finding mothers who breastfeed beyond two years. Nevertheless, the women interviewed with different characteristics and experiences contributed richness and variability to the accounts and, in turn, consistency in the similarities with respect to their motivations. When the theoretical saturation of one of the categories was incomplete, participants who had mentioned these aspects were re-interviewed to deepen their responses in order to complete the analysis of the dimensions in which these categories were involved. This validates the results expressed within the conceptual framework that structures the motivation to prolong breastfeeding beyond two years in the 21^stcentury.

Conclusion

These results lead to the conclusion that the intrinsic and transcendent motivations are the basis for decision-making in the prolongation of breastfeeding. The women who, in their childhood, integrated prolonged breastfeeding as something natural did not need further encouragement. Nevertheless, motivating the prolongation of the breastfeeding period must be accompanied more consistently by the associated benefits, and the partner or other family member significant to the woman must be included more forcefully as an active and empowering agent. These actions, which should be included in health check-ups as well as in guidelines and recommendations, would reinforce on the one hand the pre-established motivations and, on the other, would stimulate intrinsic and transcendent motivations in those women who have had little exposure to previous experiences. Although the extrinsic motivation does not apply to this aspect of child-rearing, perhaps if society achieves a culture of breastfeeding so relevant that mothers who prolong their nursing gain important social recognition, such motivation can also be included.

Acknowledgements

The authors acknowledge to Master’s Program in Community Public Health and Local Development of the Universidad de La Frontera, Temuco, Chile, for the research training support to Gloria Martinez-Poblete. Also, acknowledgements to Research Bureau of Universidad de La Frontera (DIUFRO) for financial support.

Referências

• ¹
  Horta BL, de Sousa BA, de Mola CL. Breastfeeding and neurodevelopmental outcomes. Curr Opin Clin Nutr Metab Care. 2018;21(3):174–8.
• ²
  Leon-Cava N, Lutter C, Ross J, Martin L. Cuantificación de los beneficios de la lactancia materna: reseña de la evidencia [Internet]Washington (DC): Organización Panamericana de la Salud; 2002. 186p. [cited 2019 Jan 6]. Available from: http://iris.paho.org/xmlui/bitstream/handle/123456789/18539/9275123977_esp.pdf?sequence=1&isAllowed=y
  » http://iris.paho.org/xmlui/bitstream/handle/123456789/18539/9275123977_esp.pdf?sequence=1&isAllowed=y
• ³
  Victora CG, Bahl R, Barros AJ, França GV, Horton S, Krasevec J, et al.; Lancet Breastfeeding Series Group. Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect. Lancet. 2016;387(10017):475–90.
• ⁴
  World Health Organization and UNICEF. Global strategy for infant and young child feeding [Internet]. Geneve: WHO; 2003. 30p. [cited 2019 Jan 6]. Available from: http://www.who.int/nutrition/publications/gs_infant_feeding_text_eng.pdf
  » http://www.who.int/nutrition/publications/gs_infant_feeding_text_eng.pdf
• ⁵
  Fondo de las Naciones Unidas para la Infancia. A partir de la primera hora de vida [Internet]. New York, USA: Fondo de las Naciones Unidas para la Infancia; 2016. 103p. [cited 2019 Jan 13]. Available from: https://data.unicef.org/wp-content/uploads/2016/08/From-the-first-hour-of-life.pdf
  » https://data.unicef.org/wp-content/uploads/2016/08/From-the-first-hour-of-life.pdf
• ⁶
  Española de Pediatría A. Comité de Lactancia Materna. Lactancia materna en cifras: tasas de inicio y duración de la lactancia en España y en otros países [Internet]. Madrid: Asociación Española de Pediatría; 2016. 9p. [cited 2019 Jan 13]. Available from http://www.aeped.es/sites/default/files/documentos/201602-lactancia-materna-cifras.pdf
  » http://www.aeped.es/sites/default/files/documentos/201602-lactancia-materna-cifras.pdf
• ⁷
  de Salud M. Subsecretaría de redes asistenciales. Gobierno de Chile. Orientaciones Técnicas Metas Sanitarias 2017 [Internet]. Chile: Ministerio de Salud; 2016. 49p. [cited 2019 Jan 20]. Available from http://www.araucanianorte.cl/images/PDF-WORD/OT_METAS_sanitarias_2017-31-09-2016.pdf
  » http://www.araucanianorte.cl/images/PDF-WORD/OT_METAS_sanitarias_2017-31-09-2016.pdf
• ⁸
  Sadler M, Obach A. Pautas de Crianza Mapuche [Internet]. Chile: Ministerio de Planificación, Gobierno de Chile; 2006. 78 p. [cited 2019 Jan 20]. Available from http://www.crececontigo.gob.cl/wp-content/uploads/2015/11/03-Pautas-de-crianza-mapuche.pdf
  » http://www.crececontigo.gob.cl/wp-content/uploads/2015/11/03-Pautas-de-crianza-mapuche.pdf
• ⁹
  Binns C, Lee M, Low WY. The long-term public health benefits of breastfeeding. Asia Pac J Public Health. 2016;28(1):7–14.
• ¹⁰
  Goldman AS, Goldblum RM, Garza C. Immunologic components in human milk during the second year of lactation. Acta Paediatr Scand. 1983;72(3):461–2.
• ¹¹
  Ladomenou F, Kafatos A, Galanakis E. Risk factors related to intention to breastfeed, early weaning and suboptimal duration of breastfeeding. Acta Paediatr. 2007;96(10):1441–4.
• ¹²
  Huang Y, Ouyang YQ, Redding SR. Maternal prepregnancy body mass index, gestational weight gain, and cessation of breastfeeding: a systematic review and meta-analysis. Breastfeeding Med. 2019; 14(6):366-74.
• ¹³
  Ryan RM, Deci EL. La teoría de la autodeterminación y la facilitación de la motivación intrínseca, el desarrollo social y el bienestar. Am Psychol. 2000;55(1):68–78.
• ¹⁴
  García A. Una Nueva Teoría de Motivación: El Modelo Antropológico de Juan Antonio Pérez López. Rev Puertorriquena Psicol. 2004;15:123–63.
• ¹⁵
  Stuebe AM, Schwarz EB. The risks and benefits of infant feeding practices for women and their children. J Perinatol. 2010;30(3):155–62.
• ¹⁶
  Strauss A, Corbin J. Bases de la investigación cualitativa: técnicas y procedimientos para desarrollar la teoría fundamentada. 1a ed. Colombia: Editorial Universidad de Antoquia; 2002. p. 219-35.
• ¹⁷
  Moser A, Korstjens I. Series: Practical guidance to qualitative research. Part 3: Sampling, data collection and analysis. Eur J Gen Pract. 2018;24(1):9–18.
• ¹⁸
  Glasser BG, Strauss AL. The discovery of Grounded Theory: Strategies for qualitative research. New York, USA: Routledge; 2017.
• ¹⁹
  Broc MA. Motivación y rendimiento académico en alumnos de educación secundaria obligatoria y bachillerato LOGSE. Rev Educ. 2006;340:379–414.
• ²⁰
  Howard J, Gagné M, Morin AJ, Van den Broeck A. Motivation profiles at work: A self-determination theory approach. J Vocat Behav. 2016;(95–96):74–89.
• ²¹
  Kusurkar RA, Croiset G, Ten Cate TJ. Twelve tips to stimulate intrinsic motivation in students through autonomy-supportive classroom teaching derived from self-determination theory. Med Teach. 2011;33(12):978–82.
• ²²
  Wang WT, Hou YP. Motivations of employees’ knowledge sharing behaviors: A self-determination perspective. Inform Organ-UK. 2015;25(1):1–26.
• ²³
  Schiefele U, Löweke S. The nature, development, and effects of elementary students’ reading motivation profiles. read Res Q. 2018;53(4):405–21.
• ²⁴
  Gribble KD. Long-term breastfeeding; changing attitudes and overcoming challenges. Breastfeed Rev. 2008;16(1):5–15.
• ²⁵
  Edwards R. An Exploration of maternal satisfaction with breastfeeding as a clinically relevant measure of breastfeeding success. J Hum Lact. 2018;34(1):93–6.
• ²⁶
  Scharfe E. Maternal attachment representations and initiation and duration of breastfeeding. J Hum Lact. 2012;28(2):218–25.
• ²⁷
  Schmied V, Lupton D. Blurring the boundaries: breastfeeding and maternal subjectivity. Sociol Health Illn. 2001;23(2):234–50.
• ²⁸
  Carrascoza KC, Costa AL Junior, Ambrosano GM, Alves de Moraes AB. Prolongamento da amamentação após o primeiro ano de vida: argumentos das mães. Psicol, Teor Pesqui. 2005;21(3):271–7.
• ²⁹
  Newman KL, Williamson IR. Why aren’t you stopping now?!’ Exploring accounts of white women breastfeeding beyond six months in the East of England. Appetite. 2018;129:228–35.
• ³⁰
  Susin LR, Giugliani ER, Kummer SC. Influence of grandmothers on breastfeeding practices. Rev Saude Publica. 2005;39(2):141–7.
• ³¹
  Dowling S, Brown A. An exploration of the experiences of mothers who breastfeed long-term: what are the issues and why does it matter? Breastfeed Med. 2013;8(1):45–52.
• ³²
  Galvão DM, da Silva IA. Portuguese school children breastfeeding experiences. Rev Esc Enferm USP. 2011;45(5):1055–62.
• ³³
  Dornan L, Sinclair M, Kernohan WG, Stockdale J, Khuwuthyakorn V, Suppasan P. Thai cultural influences on breastfeeding behaviour. Evid Based Midwifery. 2015;13(3):84–91.
• ³⁴
  Dettwyler KA. When to wean: biological versus cultural perspectives. Clin Obstet Gynecol. 2004;47(3):712–23.

Publication Dates

• Publication in this collection
  28 Aug 2020
• Date of issue
  2020

History

• Received
  8 May 2019
• Accepted
  11 Nov 2019