FACTORS ASSOCIATED WITH BREASTFEEDING SELF-EFFICACY IN THE IMMEDIATE PUERPERIUM IN A PUBLIC MATERNITY HOSPITAL

Objective: to verify the association between sociodemographic variables, obstetric history, current pregnancy, and puerperium with breastfeeding self-efficacy. Method: cross-sectional study conducted in southwestern Maranhão, Brazil, between October 2020 and July 2021 with the participation of 240 postpartum women, using the Breastfeeding Self-Efficacy Scale - Short Form. Descriptive analysis, possible associations, simple and multiple logistic regression models were performed. Results: 83.3% had high breastfeeding self-efficacy, 46.7% were between 26 and 35 years old, 81.2% were married or in a stable union, 94.2% breastfed in the first hour of life, 37.9% received orientation on breastfeeding in the Primary Health Care Unit, and 84.2% offered only breast milk to the newborn in the maternity hospital. These factors were associated with high breastfeeding self-efficacy (p<0.05). Conclusion: The research contributed to guide health professionals to provide superior quality care


INTRODUCTION
The attitude of breastfeeding is linked to a historical, sociodemographic, and emotional scenario, having peculiar definitions for each woman.Although the importance of women as protagonists in the promotion of breastfeeding is acknowledged, this attribution also permeates the collective social burden under the strong influence of the current model of breastfeeding (BF) adopted by the programs of the National Policy for the Promotion, Protection, and Support of Breastfeeding.In this context, despite the result of lower health care costs, reduced rates of breastfeeding are still perceived 1 .
Despite initiating exclusive breastfeeding (EBF) in the immediate postpartum period, many mothers complement or abandon this practice in the first weeks.This is due to several factors, such as breast problems, insufficient milk production, and the baby's difficulty in sucking 2 .It is also possible to highlight the mother's socioeconomic status, level of education, her condition regarding being primiparous or multiparous, emotional factors, lack of family encouragement, genuine intention to breastfeed, and lack of knowledge on the subject by the mother 3 .
The World Health Organization (WHO) characterizes as good the percentage of 50% to 89% of children on EB and as very good if above 90% [4][5] .In Brazil, in 2020, there was an increase in the prevalence of continued BF in the first hour of life (53.1%)and EBF among children up to four months old (60%), outlining a scenario adjacent to the global goal for 2030, which is to reach about 70% in these indicators.Moreover, a similar parameter was noted in the advancement of the prevalence of breastfeeding in children under two years of age, reaching (60.9%) 6 .It is believed that this level rises in line with the policies recommended by the WHO/United Nations Children's Fund (UNICEF) and the Ministry of Health [4][5] .
Recent studies have revealed that lactating women are held responsible for the practice of breastfeeding, highlighting their positive expectations for breastfeeding their children; however, they often disregard their desires, needs, and insecurities regarding the context of caring for the newborn (NB) 7 .Self-efficacy is an improvement in personal ability to successfully perform certain tasks or behaviors to achieve likely results, being considered a modellable factor [8][9] .
Given the importance of self-efficacy, a breastfeeding self-efficacy scale (BSES), the Breastfeeding Self-Efficacy Scale -Short Form (BSES-SF), was developed in Canada to assess the confidence of nursing mothers in breastfeeding [10][11] .The short version of the BSES, already validated in Brazil, allows us to know in advance the area in which women have lower breastfeeding self-efficacy, enabling, when necessary, the implementation of actions and care strategies with individualized interventions to optimize breastfeeding promotion assistance before deciding not to breastfeed or to wean early [12][13] .
To verify and understand the mother's self-confidence and satisfaction in the breastfeeding process, it is useful to assess breastfeeding self-efficacy.The self-efficacy theory, proposed by Albert Bandura, a Canadian psychologist, proposes to expand the individual's perception of his abilities when performing a certain activity 8 .It is believed that the existence of a health education strategy applicable to the hospital setting may increase not only maternal self-efficacy in breastfeeding, but also breastfeeding rates and the prolongation of complementary breastfeeding.
This study aimed to verify the association between sociodemographic variables, obstetric history, current pregnancy, and puerperium to breastfeeding self-efficacy.This is a cross-sectional, exploratory research with quantitative approach, conducted in a large public maternity hospital, located in the southwest of the state of Maranhão, inserted in the Iniciativa Hospital Amigo da Criança -IHAC (Child Friendly Hospital Initiative), of tertiary reference in perinatal and neonatal care.The research was conducted in the period from October 2020 to July 2021, and data collection occurred between January and March 2021.The steps of this methodology were guided by the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) tool.
About 450 normal and surgical deliveries were performed monthly.Considering a 90% confidence interval and a 5% sampling error, the sample comprised 240 puerperal, and the criterion of convenience was adopted for the selection of participants.Included were puerperal aged 18 years and older, in immediate puerperium, between eight and 48 hours postpartum, admitted to the rooming house, who were on EBF and in the period of at least six hours postpartum.Were excluded: those younger than 18 years old; with children hospitalized in the neonatal intensive care unit; who, in the immediate postpartum period, had clinical and obstetric complications and pathologies that contraindicated breastfeeding and/or prevented communication with the researcher.
An adapted survey instrument 14 was used, composed of 22 closed questions containing sociodemographic characteristics (age, race, marital status, education, occupation, and family income) and obstetric data (number of children, parity, history of prematurity, previous breastfeeding practice, main reasons for breastfeeding, whether breastfeeding was interrupted, and factors that hindered or prevented breastfeeding).The questions about current pregnancy and puerperium contained information about prenatal care; breastfeeding in the first hour; how long they intended to breastfeed exclusively; whether they received guidance on breastfeeding, where and by which professional, and whether formula was offered to the NB in the maternity hospital.
The BSES-SF, originally constructed in Canada 15 , abbreviated, and translated into Portuguese 10 , is constituted, in the original form, by 33 items and, in the short form, by 14 items, which are divided into two domains: Technique (eight items) and Intrapersonal Thoughts (six items).The scale is based on the Likert-type opinion criterion, which specifies the level of agreement on a statement, resulting in a score obtained based on the sum of each item: low effectiveness (14 to 32 points), medium (33 to 51 points) and high (52 to 70 points) 10 .After checking for errors and inconsistencies, descriptive analysis was performed using absolute and relative frequencies for all investigated variables and self-efficacy.
To evaluate possible associations between self-efficacy and the variables under investigation, simple and multiple logistic regression models 16 were used, since the response was binary (high self-efficacy: yes or no).To select the main risk factors, univariate logistic analysis (unadjusted) was initially performed, considering as selection criteria all the variables that presented a p-value < 0.20.Subsequently, multivariate logistic regression (adjusted) was performed with these selected variables to estimate the odds ratios (OR), with confidence intervals of 95% and a significance level of 5%.There was no multicollinearity among the independent variables evaluated 17 .All tests were performed in IBM Statistical Package for the Social Sciences (SPSS), version 24, at 5% significance level.

RESULTS
The minimum age of the participants was 18 years and the maximum, 46 years with a range of 28 years, mean of 27.6 years, standard deviation of 6.02 years, and median of 27 years.The 112 (46.7%) participants or puerperal women were between 26 and 35 years old, 104 (43.3%) were yellow, 195 (81.2%) were married or in a stable union, 149 (62.1%) had schooling between eight and 12 years old, 194 (80.0%) had no employment relationship, and 127 (52.9%) had family income between one and two minimum wages (Table 1).Regarding obstetric history, 149 (62.1%) of them had between two and three children, 86 (35.8%) were second parity, 180 (75.0%) of the participants had no history of prematurity, 167 (69.6%) had breastfed during a previous pregnancy, 90 (37.5%) reported feeling of obligation as a reason for breastfeeding their children, and 162 (67.5%) did not stop breastfeeding.Among the 42 (53.9%)who stopped breastfeeding, the reason was insufficient milk production.
In the univariate analysis, the variables age 26 to 35 years and over 36 years, married or stable union, education < eight years and between eight and 12 years, no employment relationship, family income from one to two minimum wages, two to three children, breastfeeding in the newborn's first hour of life, guidance on breastfeeding in the UBS, and only breast milk as the newborn's food in the maternity ward showed a statistically significant association with high breastfeeding self-efficacy (p<0.20)(Table 2).In the multivariate analysis (adjusted), the variables: age 26 to 35 years; over 36 years; married or in a stable union; no employment relationship; breastfeeding in the first hour of life of the newborn; orientation about breastfeeding in the BHU; and only breast milk as food for the newborn in the maternity ward remained associated with high self-efficacy in breastfeeding in women in the immediate postpartum period (p<0.05)(Table 3).

DISCUSSION
Specific information on breastfeeding during the prenatal and postpartum periods is essential to ensure the best assistance and prevention of early weaning, providing a successful experience in the breastfeeding process 18 .
Maternal age is a relevant factor in adherence to and duration of breastfeeding.In this study, with increasing age, there were three times more chances of occurrence of high breastfeeding self-efficacy when compared to puerperal of younger age.This corroborates the literature, which showed that women over 35 years old were 21.18 times more likely to have higher levels of self-efficacy, and those between 26 and 35 years old were only 12.59 times more likely to have higher BSES scores 19 .
On the other hand, a study with puerperal adolescents showed that most of them (54.26%) had a high level of self-efficacy in the ability to breastfeed because they received help from their mother and mother-in-law.This fact proves that certain practices, such as receiving support and initiating breastfeeding in the first hour of life, influence the increase in maternal breastfeeding self-efficacy 20 .
Regarding marital status, 195 participants (81.2%) were married or had a stable union and more chances of high breastfeeding self-efficacy (OR=3.0).A study conducted in Uganda, West Africa, with the participation of 84 postpartum women indicated that six out of 10 women had high self-efficacy for breastfeeding, and the associated factors were the presence of a partner and receiving support from health professionals for breastfeeding in the immediate postpartum period 21 .It is also emphasized that the presence of a partner is important for the support and encouragement provided, which positively influences the success of breastfeeding, and its absence may be a determining factor for early weaning 22 .
Another determining factor in the practice of EBF is related to the non-formal insertion of this group in the labor market, with no employment relationship, thus leading to home care, in addition to intervening in the reduction of family income of most mothers 3 .In a study of 135 nursing mothers, 64.5% were engaged only in household activities 23 .
Being a housewife is considered a protective factor for BF, because the return to work is the main cause of early weaning for some mothers, in addition to anticipating complementary feeding, which may interfere with the child's growth and development 3,23 .Therefore, the participants in this study had a favorable situation for the practice of BF, considering that most of them, at the time, were not employed.
It is known that adequate guidance during prenatal and postpartum periods favors self-confidence in breastfeeding.For these reasons, since prenatal care, pregnant women should be encouraged to breastfeed their babies and informed about the benefits of the practice and the disadvantages of other milks 24 .However, in this study, some women did not receive any prior information about breastfeeding during prenatal care or even at the maternity hospital.
A systematic review compared the types of BF counseling (individual and group), aiming to verify its effect on the rates of EBF within 48 hours postpartum, in the first month, and between one and five months.The results showed a significant 43% increase in EBF within 48 hours postpartum when mothers received individual counseling 25 .Thus, correct information on the breastfeeding process favors greater confidence for mothers to breastfeed soon after birth 26 .
This study pointed out a significant association between breastfeeding self-efficacy and the variables parity and type of feeding in maternity.In divergence to this result, a study 27 detected a statistically significant association between low birth weight and not breastfeeding in the first hour after birth, even after adjustment.There was no association between the type of delivery and breastfeeding in the first hour of life.Therefore, the mother's decision-making power is limited, since the professionals' knowledge and the practices instituted in the hospital service are configured as determining factors for the initiation of breastfeeding in the delivery room.Corroborating this finding, a study conducted in Sweden found that multiparous mothers had higher BSES-SF scores 28 .Given this issue, high self-efficacy in multiparous women is justified as a protective factor for the success of subsequent pregnancies.
The early initiation of breastfeeding brings benefits for both mother and baby and is related to the woman's greater satisfaction and confidence in her ability to breastfeed and care for her baby 20 .A systematic literature review showed that breastfeeding in the first postpartum hour under free demand, the child's stay in the rooming-in unit, the professionals' intervention when breast complications occur, and the restriction of supplementation for infants were listed as protective factors of in-hospital EBF, despite the short stay in the maternity hospital 29 .
Among the potentialities of this study, the use of the BSES for the BSES-SF Breastfeeding stands out.This is a scale recognized and used worldwide, making it possible to compare the results of the studies 9 .Moreover, in a systematic review with only longitudinal studies, relating the duration of EBF and the total score of the BSES-SF, it was found that of the total of four studies, three identified a significant increase in EBF over six months.Only one study did not show this association 30 .Given this approach, it is believed that the success of breastfeeding depends on favorable measures that can influence those involved in a satisfactory manner, prioritizing the factors that are directly related to the mothers and the situational factors of living conditions.One of the limitations encountered during the study was the difficulty of access of the researcher to hospital environments due to decrees and restrictions on the number of hospitalizations of pregnant women, making data collection more complex in this period of pandemic.In addition, because it was a cross-sectional study, the characteristics related to BF were related to a short and limited time (the moment of the interview), making memory bias possible because it is a period of hormonal and physiological alternations, which can compromise the accuracy of the information.
In the immediate puerperium, the woman should be accompanied by health professionals in the rooming-in and supported in her lactation practice, so that she has support in her difficulties, being directed to childcare consultations, aiming to maintain her confidence and self-efficacy in breastfeeding.
Mothers showed high self-efficacy for breastfeeding, a satisfactory finding for the practice of breastfeeding.In the univariate and multivariate (adjusted) analysis, the variables that were significant for high self-efficacy were age 26-35 years and older than 36 years, married or in a stable union, no employment relationship, breastfeeding within the first hour of life of the newborn, guidance on breastfeeding in the Primary Health Care Unit, and only breast milk as food for the newborn in the maternity hospital.
Knowing the sociodemographic and obstetric profile of this population contributes to guide health professionals to provide superior quality care to pregnant, postpartum, and breastfeeding women, aiming to increase breastfeeding self-efficacy, identifying those who need greater support.Longitudinal studies are suggested to follow up pregnant women to delineate the behavioral trend of breastfeeding.

CONCLUSION
The research was approved by the Research Ethics Committee of the Federal University of Maranhão, under opinion number 3,938,561.METHODSCogitare Enferm.2023, v28:e88970 Factors associated with breastfeeding self-efficacy in the immediate puerperium in a public maternity hospital Siqueira LS, Santos FS, Santos RM de MS, Santos LFS, Santos LH dos, Pascoal LM, et al.
This study was funded by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior -Brasil CAPES (Coordination for the Improvement of Higher Education Personnel -Brazil (CAPES) -Finance Code 001.To the Fundação de Amparo à Pesquisa e ao Desenvolvimento Científico e Tecnológico do Maranhão, Foundation for the Support of Research and Scientific and Technological Development of Maranhão, FAPEMA.FAPEMA Resolution no.07, of 05/03/2022.

Table 2 -
Univariate analysis of sociodemographic characteristics, obstetric history, and current pregnancy and immediate puerperium in relation to high self-efficacy in breastfeeding.Imperatriz (MA), Brazil, 2021 Cogitare Enferm.2023,v28:e88970Factors associated with breastfeeding self-efficacy in the immediate puerperium in a public maternity hospital Siqueira LS, Santos FS, Santos RM de MS, Santos LFS, Santos LH dos, Pascoal LM, et al.Source: authors (2021).*Wald chi-square; † value of minimum wage R$ 1,100.00;‡ presence of zero values that make it impossible to calculate the OR.OR: odds ratio; CI95%: 95% confidence interval; BHU: Basic Health Unit.