Breastfeeding as a human right: construction of educational material by the voice of women

Breastfeeding is recognized as a determining practice in the promotion of women’s and children’s health. To protect it is to act in guaranteeing Food and Nutrition Security. The aim of this study is to describe the process of creating educational material to promote breastfeeding in the hospital environment. This is a qualitative study, involving semi-structured interviews with 13 women assisted in a public maternity hospital in the city of Rio de Janeiro, followed by the development and evaluation of the resource. The material was created based on principles of food and nutrition education, on the women’s narratives and on the comprehension of breastfeeding as a human right. It was concluded that the participation of those who breastfeed in the preparation of the material provided the opportunity for protagonism and the representation of concrete experiences about this practice.


Introduction
The importance of breastfeeding and its multidimensional influence on the health of women and children has been evidenced by consistent scientific studies on the subject. Breastfeeding is recognized as a practice of relevant social impact, determinant to human development 1 .
In Brazil, efforts aimed at encouraging breastfeeding have been observed since the 1970s, with the intention of generating the structuring of the national policy for the promotion, protection, and support of breastfeeding. Advances in this regard have contributed to the improvement of indicators related to breastfeeding 2,3 . However, the success of breastfeeding is associated to the women's living conditions and decisions, the health status of the woman and the baby, the sociocultural context of the families, and the strengthening of support networks.
We must overcome the naive, limited and fragmented maternal vision that still prevails in the discourse of some breastfeeding policies and strategies. which usually focus on the positive aspects of breastfeeding, observing only the woman's responsibility, without considering the complexity for its full realization 4,5 .
The encouragement of breastfeeding is part of the scope of initiatives in the area of food and nutrition that promote the Human Right to Adequate Food. The right to food must be guaranteed from the first hour of life, and breastfeeding is indispensable for Food and Nutrition Security (FNS) 6 .
The Brazilian National Policy on Food and Nutrition Security is committed to food and nutrition actions at all levels of health care and has as one of its goals the protection, promotion, and support of breastfeeding. It seeks to promote and protect adequate and healthy food for the Brazilian population, also through actions of Food and Nutrition Education 7,8 .
Within the Health Care Network of the Unified Health System, maternity hospitals are fundamental support environments for the practice of breastfeeding. These hospitals can work as places for humanized actions, enhancing the realization of breastfeeding from the beginning of life. An example is the implementation of actions to encourage breastfeeding through critical-reflective educational strategies, together with the health workers, women and other family members 6,9 .
The opportunity to use educational strategies in the hospital environment developed together with women, compatible with their desires, realities, and other contemporary issues that permeate the universe of breastfeeding, emerges as a possible way to improve the experiences related to breastfeeding and to ensure the Food and Nutrition Security.
Thus, the main intention of this research was to develop an educational material built by recognizing the daily life experienced by women in the breastfeeding process. Also, make it possible to use it as a resource to encourage breastfeeding in the hospital environment. This manuscript aims to describe the development process of the educational resource, from the stage of listening to women to the elaboration and evaluation of the material.

Methodology
This is a descriptive, analytical, and propositional study based on qualitative research techniques and methods.
The field research was developed in the Maria Amélia Buarque de Hollanda Maternity Hospital, integrated to the Health Care Network of the City of Rio de Janeiro. The hospital follows the guidelines and standards of the "Baby-friendly Hospital Initiative (BFHI)".
The identification of potential study participants was done by consulting the hospital files of the women admitted, which contained name, telephone number, and information about breastfeeding. The sample was delineated considering the following inclusion criteria: puerperal women assisted by the hospital, who breastfed or were breastfeeding, in good health conditions, and who agreed to participate in the study, without differentiation as to race, age or economic status. Cases in which breastfeeding was permanently contraindicated were excluded: women with human immunodeficiency virus (HIV) (other cases of absolute contraindication were not identified at the time of data collection).
Semi-structured interviews were conducted with 13 women, in the period from August to September 2020. Considering the context of the pandemic of Covid-19, the conversations were held after hospital discharge, remotely through the multiplatform application WhatsApp, recorded and transcribed verbatim.
A total of 75 files were collected and, according to the final scope of the sample, the telephone contact of 34 people was randomly and gradually extracted from the documents. From this list of contacts, 06 presented error or were unavailable for communication via WhatsApp. The invitation to participate via message by the application was forwarded to 29 women. Of these, 14 did not reply, 02 replied, but could not participate, and 13 agreed to participate in the research. The saturation of information determined the final sample size, when the interviews brought no more new elements 10 .
The semi-structured interviews were conducted based on a script organized in two blocks: the first about personal information and the experience with breastfeeding, and the second with suggestions for the educational resource, regarding contents, language, format, illustrations, etc.
The Informed Consent Form was read to the interviewees and their agreement to participate in the interview was audio recorded. The average duration of the interviews was equivalent to 30 minutes.
For the analysis and treatment of the interview data, we used the Thematic Content Analysis, proposed by Bardin 11 .
After analyzing the interviews, the development stage of the educational resource began, seeking to meet the main gaps and demands identified. The development was guided by a Creation Plan and a Production Script.
To determine the relevance of the educational resource, content and presentation, the script of the material was evaluated by the women interviewed themselves via an online form.

Results
At the time of the interview, 11 women were breastfeeding, 9 exclusively and 2 in mixed breastfeeding (human milk and artificial formula), and 2 reported early weaning. Among the interviewees, 8 were primiparous and 5 were multiparous. It is noteworthy that 8 mentioned being their first experience with breastfeeding.
The newborns had an average age of 3 months and 3 days when the interviews were conducted. The average age of the women was 30 years (minimum 21 years and maximum 39 years). The research included women from different social positions.  Source: own author.
Through the 13 interviews, five thematic categories were elaborated, presented below, and from the analyses, the educational resource was developed according to the following step-by-step: creation of a plan to build the material; elaboration of a production script; evaluation of the script by the interviewees, and production of the material.

Meaningfulness of the birth experience and its relation to breastfeeding
Women perceived childbirth beyond pain, as a positive and unique experience. For the multiparous women, it was also described as a new and different experience from previous ones, specifically when they referred to the assistance provided by the health team. The participants reported what for them is understood as "humanized childbirth": welcoming, respect, attentive listening, precise and coherent orientations. In fact, the meaning of the "humanization ofchildbirth" is polysemic and there are no rigid routines, precisely because each woman has different needs 12 .
On the other hand, in the experiences with childbirth, some speeches revealed difficulties in communication with health professionals, generating failures in the understanding and interpretation of health guidelines by women. This situation contributed to some puerperae perceiving the birth experience as traumatic, generating emotional conflicts with consequences in the breastfeeding process. Especially, within the hospital environment where the memories related to childbirth remained latent.
The sensitivity of the multiprofessional team is essential to understand the nuances related to health competencies developed by each individual throughout life and also built through the professional/patient relationship. In this direction, in the elaboration process of educational strategies, the Framework of Reference for Food and Nutrition Education for Public Policies 13 (inserted in the context of the realization of Human Right to Adequate Food and Food and Nutrition Security) recommends the adoption of approaches that favor dialogue and consider the legitimacy of different knowledge.
In addition, outcomes observed in birth experiences interfered with the realization of breastfeeding in the first hour of life. More than half of the women interviewed (7) reported not having breastfed soon after birth. Maternity hospitals should value the socalled "golden hour" as an excellent opportunity for interaction between the breastfeeder and her baby and a moment to ensure the right to adequate nutrition for the newborn. Except in cases of risks to the woman's or child's health, unnecessary interventions must be avoided and routine procedures can be performed after the first hour of birth 14 . It is necessary to value work practices within the hospital routine that recognize the importance of immediate initiation of breastfeeding and its relevance to FNS.
Activities to promote breastfeeding should be effective from before birth and early in life in order to build feeding patterns with short-to long-term effects1. As in childbirth care, the strategies to support and encourage breastfeeding should be related to a humanized and welcoming health work process throughout the woman's itinerary in the Health Care Network.

Difficulties in breastfeeding
It was possible to observe a diversity of difficulties reported by the women that can compromise the FNS of the children: difficulties with latching; establishing responsive feeding, breast engorgement; mastitis; breast lesions; nipple type; ankyloglossia; early introduction of artificial formula; hypoglycemic situations with the newborn, and; neonatal jaundice.
Facing these difficult situations, the report of pain appeared frequently, especially in the initial period of breastfeeding. There is no discussion about how each woman tolerates pain or her choices when facing difficulties, because some give up breastfeeding and others do not. However, it is known that people who have been previously oriented about the challenges are more effective in understanding and solving the difficulties related to breastfeeding. As well, they can recognize the importance and when it is necessary to ask for help 15 .
Guidance on breastfeeding management (latch, position, manual milking, interpretation of the baby's hunger signs, etc.) by the healthcare team at the onset of pain can be efficient to protect and encourage breastfeeding still in the intra-hospital environment. It is up to the health team to broaden its view, enabling early support based on guidelines that do not blame the woman, but use approach strategies such as welcoming and understanding listening. The support network also plays an important role, resignifying culturally constructed beliefs about breastfeeding.
Another difficulty encountered was breastfeeding under free demand. A confusion about the concept of "responsive feeding" was observed, both by the woman and the support network, which intensified the idea that it is the woman's duty and responsibility to always be available for her child. This is similar to the findings of Rocha et al. 16 , where one of the main negative experiences in breastfeeding was the constant demand of the child for the breast, generating fatigue and overload. A better comprehension of this recommendation can facilitate the understanding and organization of life in the face of the intense demand of the child 17 .
In some support materials, the recommendation of responsive feeding is described as: "breastfeed whenever the child asks" 18 ; "breastfeed without schedules, whenever the child requests the breast" 19 . It can be noticed that one of the intentions of this guidance is to "demystify" the idea of breastfeeding on a fixed schedule, which can bring complications to the health of the woman and the child 20 . However, it is possible to question that the emphasis on the child's needs can demotivate the woman who feels overburdened and generate obligation to offer the breast at all times.
The guidance on responsive feeding should be associated with reality, clarifying that the real demand of the child for the breast is more intense in the first weeks of breastfeeding16, associated with learning about the recognition of early and late signs of hunger of the baby. For example, a study by Siqueira and Santos 21 highlighted that nursing mothers and health professionals were unaware of the meaning of responsive feeding and recognized only crying (late sign) as a newborn's hunger sign. Thus, for women and their support network, responsive feeding: whenever the child asks, is synonymous with whenever the child cries?
Ressignifying breastfeeding under free demand, in the light of the FNS concept, it is certain that this practice ensures adequate food, permanently, without compromising access to other essential needs. In this scenario, it is the woman who produces the human milk and ensures that the child is fed, but the responsibility of ensuring this subsistence can be shared. For example, with the support of her network and through strategies that can minimize the feeling of overload, such as expressing milk by hand and offering expressed milk to the child by the partner at certain times.
The difficulties related to breastfeeding were also associated with the lack of information about this practice. The lack of knowledge on the subject can lead to insecurity and uncertainty during the experience 22 . Evidence suggests that educational activities on breastfeeding should take place from the prenatal to the puerperium, especially playful activities that have a positive influence on the practice of breastfeeding 23 . The period when the woman and her baby stay in the hospital is an opportunity for health professionals to talk about breastfeeding, demonstrating its importance and guaranteeing information that is not superficial 22,24 . The importance of improvements in the work process of teams committed to women's and children's health is revealed, strengthening continuing education in health.

Reasons to breastfeed
Reflecting on the motivation to breastfeed, all the interviewees knew some or more than one benefit related to human milk and characterized it as a healthy and complete food. The positive dimensions related to women's health were also mentioned. However, it is noteworthy that the importance of breastfeeding for the child's health appeared as the main reason for breastfeeding and also for maintaining the practice even when faced with difficulties. A correlated study identified similar narratives, with its importance to the child's health also being the most frequent reason 25 .
It is noted that the reasons for breastfeeding extended to the biopsychosocial characteristics, including the bond between the woman and the baby. Did the women express the real affective bond built in this relationship or did they only reproduce a common statement in guidelines related to the encouragement of breastfeeding? In this study, other dialogues seemed to reveal this bond with more intensity. The bond was implicit and translated especially into pleasure, exchange, and connection when breastfeeding.
For women, breastfeeding was perceived as a sustainable, affordable and safe practice. Human milk is unique and unparalleled, ideal for the child and suited to its needs 2 . In other words, as they themselves described it: complete. From a FNS perspective, breastfeeding is a sustainable and health-promoting food practice 26 . According to the Political Charter of the 5a National Conference on Food Security and Nutrition, human milk is real food, respects the rights and encourages the protagonism of women 27 .
Along with these factors, women's support networks were also placed as a motivating aspect. Social ties help minimize the woman's sense of loneliness and burden. The sharing of knowledge and experiences and the support of family units, health professionals, and other networks can influence the adherence and continuity of breastfeeding16. Of the 13 interviewees, 10 reported needing help to breastfeed.
From the reports, it could be perceived the partner's role as one of the most influential actors in this process. For the interviewees, the participation of the partner in breastfeeding was related to the idea of co-responsibility for the child's care, which does not see the woman only as a provider of food for the baby. The partner represents the daily support, and can assume tasks related to the care of the newborn, domestic activities, among others, so that the woman has more time to dedicate to breastfeeding. In addition, he can offer comfort and emotional support, understanding the changes she faces during this period 28 .
Over the years, the campaigns in favor of breastfeeding in Brazil have started to include the family and society as responsible for the breastfeeding process 29 . It is noted that when developing educational resources to promote breastfeeding, we should think of strategies that permeate a family and community approach and give special emphasis on the participation of the partner 18,29 .
Breastfeeding: a process of adaptation and learning Breastfeeding was not described by the women in a romanticized way and the difficulties, unlike childbirth in which pain was already imagined, appeared as something unexpected. The need for more preparation and contact with the theme of breastfeeding since pregnancy and, according to them, from a look at reality was highlighted.
They reported that breastfeeding is not something intuitive, it is a constructed process that does not depend only on the woman and is associated with the relational dynamics of families and the daily life of breastfeeding people. The woman who breastfeeds plays other social roles and suffers with triple work shifts and additional demands to specific norms already required to "be a mother". They challenged the "contemporary ideology of motherhood" that sees only one way to be a mother: benevolent, passive, and fully dedicated to the child(ren) 30 . They deconstructed this stigma by stating that no woman is more or less of a mother by not breastfeeding.
In studies that explore the analysis of the discourses constructed in educational materials supporting breastfeeding in Brazil, breastfeeding is perceived through a reductionist view, focusing on the child's health, excluding or standardizing the women's perspective on the process and even objectifying them. Added to this is the use of a directive language, presuming the compliance of certain practices by the women 29,31,32 . The intention is not to disregard the importance of breastfeeding for the child, but to rethink the ways of building breastfeeding protection strategies, reflecting on what women have to say and want to know about this practice.
A systematic review on the perception of postpartum women evaluated that a positive puerperal experience is one in which women are able to adapt to their new identity (wife and mother) and develop a sense of confidence, including self-esteem, autonomy, relationship with the baby, and coping with physical and emotional challenges 33 . Similarly, the women interviewed defined breastfeeding as a process of adaptation and learning that involves the breastfeeder, the baby, the family, the healthcare team, and the support network.
Among the participants, 9 were exclusively breastfeeding, a positive finding. However, some interviewees reported decreased milk production, possibly attributed to emotional factors. In the case of breastfeeding women, stress can negatively interfere with breastfeeding 34 . Maternal insecurity regarding the guarantee of feeding the child, the ability to fully nourish her child, and the maintenance of exclusive breastfeeding was observed, which may represent unfavorable outcomes for breastfeeding.
On the path to ensuring the FNS and with regard to the practice of breastfeeding, the health of the child and the woman are not opposites, there is no dissociation between them. Therefore, the safety of the person who breastfeeds must be accompanied in a joint manner, considering: listening to the woman as a protagonist in this process; breastfeeding as a complex and learned practice; the risk of psychosocial vulnerabilities interconnected to the sociocultural ideals around maternity to which the woman is exposed; the guarantee of maternity leave and other measures that support and protect during this period. This paradigm should serve as a basis for the development of materials to encourage breastfeeding 29 .
The experience with breastfeeding in the pandemic of Covid-19 Since this study took place amidst the backdrop of the Covid-19 pandemic, we sought to understand its influence on breastfeeding performance.
Regarding social distancing, the women reported that the care with personal and environmental hygiene, necessary for the prevention of Covid-19 at that moment, were intensified after the birth of the baby. For them, the newborn is seen as a fragile being who needs special care 35 . In the context of the pandemic, measures to avoid exposure to the coronavirus were added to this care, and feelings of fear, insecurity, and greater concern for the child's health were observed.
Another fact highlighted was the concern with the safety of breastfeeding in case they contracted the virus. This is because in relation to Covid-19, uncertainties and doubts about the disease as forms of transmission and contamination still prevailed. It is important that the woman, if her health status allows, feel comfortable to decide whether or not to continue breastfeeding in case of suspicion of Covid-19 or confirmation. And if she chooses not to breastfeed, it is necessary to ensure means to feed the child with human milk through other feeding alternatives, reaffirming its importance as a safe source of food 36 .
Exclusive breastfeeding appeared as a condition that is more feasible and reliable in terms of ensuring adequate nutrition for the child. For example, in the case of children on mixed feeding and artificially fed, the participants described that care with hygiene in the provision of food would be less frequent if only human milk was offered, since artificial formula "came from the market". In this case, a greater concern with food safety was observed. This is because, in the understanding of the women interviewed during the study period, this type of feeding could offer greater risks of exposure to the Covid-19 virus.
With the pandemic of Covid-19 and in the face of all the social impact and redoubled health care, the challenge of guaranteeing the Human Right to Adequate Food is even greater 37 . It is known that in public health emergencies, breastfeeding is the safest way to feed babies, preventing the occurrence of food and nutritional insecurity, especially when other types of food may be less accessible. Human milk, due to its protective potential, can mitigate the effects of infections 38 . Following official recommendations, protocols established by institutions and evaluating on a case-bycase basis, it is known that women can and should continue to breastfeed their babies even in case of coronavirus infection 39 .

Process of Elaboration of the Educational Material
Of the 13 interviewees, 9 suggested short videos as an ideal format for people who breastfeed. This type of material, available for sharing on the social network, is accessible, facilitates the dissemination, the sharing of experiences among peers 40 and, according to the interviewees, is an advisable format for guidance on the subject in the context of a pandemic.
The outcome of the research resulted in the creation and production of a set of videos entitled "Isabel's Story with Breastfeeding" (d) consisting of four microvideos, with an average duration of 3:34 minutes, 1 introductory video and 3 thematic videos. The production process involved: development of a plan to create the educational resource (Frame 1); development of a production script containing the organization and contents of the 4 microvideos; evaluation of the script by the research participants, who were invited to read the story that would be portrayed in the videos and to fill out a form with their perceptions; production of the videos, which had the collaboration of an educator with experience in creating audiovisual educational materials. Objectives: to promote breastfeeding in the hospital environment; to offer reliable information, promote reflection, and create playful moments.
Audience: women, family, and support network. Usage possibilities: sharing on social networks (youtube, whatsapp, facebook, instagram) and by maternity professionals.
Source: own author.
The educational resource, developed after evaluation, had as its main objective to present content on breastfeeding portrayed from the perspective of women. As also, it aimed to bring essential information for the promotion of breastfeeding in order to ensure the FNS. It sought to dialogue with people, through accessible language and close to reality. It highlighted breastfeeding as a right and the relationship of breastfeeding with the family and professionals involved in the process. It can be a source of information and an educational tool also for support networks and health teams. The series of videos developed can be used in breastfeeding care, whether in the hospital or at home, or in the continuing education activities of health teams, and can be shared on digital media.
Regarding the limitations of the study, it was highlighted in the preparation of the material the difficulty in incorporating the range of issues raised by the women: taking into account all the experiences and diversities related to breastfeeding; the existing family compositions; and the women's life and work dynamics. There were also limits to contemplate in the series of videos the set of critical reflections built in the thematic analyses, since there was a need to share essential technical information, such as guidelines on latching and positions to breastfeed, the physiology of lactation, among others.

Concluding remarks
The narratives of women who breastfeed are vast and are not restricted to the dimensions constructed in this study. The creation of the educational material prioritized looking at the real demands, doubts, and difficulties identified by them in the practice of breastfeeding, highlighting breastfeeding as a process of learning and adaptations.
The importance of recognizing breastfeeding as a child and woman's right and as a practice that guarantees FNS was demonstrated. In addition, it is essential to expand access to information on breastfeeding as a way to contribute to the greater preparation of breastfeeders for the challenges faced in the experience and collaborate to the success of this practice.
Regarding the construction process of the series of educational videos, listening to and interpreting the experiences described by the women allowed to unite many experiences into one, but not limited to the resource itself. The results of the research extended beyond the material and revealed themselves during its construction, by bringing new perspectives to the practice of breastfeeding. Therefore, by being represented and recognized, breastfeeding mothers can be protagonists in their experiences with breastfeeding.