IDENTIFICATION OF THE DOUBTS AND DIFFICULTIES OF PREGNANT AND POSTPARTUM WOMEN RELATED TO BREASTFEEDING

Conflict of interest: non-existent The breastfeeding correctly stimulates the sensory oral motor system from the newborn, because the milk extraction needs muscular power, and it increases the tonicity of the muscle, and stimulates the speech, breathing, swallowing and the facial and oral structures3-5. The regular muscular function favors the increasing and developing of the jaw6. A child that did not pass through breastfeeding, or passed in a short period, can develop atypical swallowing, phonoarticulatory and neurosensory disorders, and deleterious oral habits, as the non-nutritious suction exemplified by the thumb and/or pacifier, in order to meet the minimum number of suction that occur in a bottle feeding, not reaching the emotional ecstasy7. Consequently, it may occur alterations on the dental arch and palate, reflecting in the occlusion and articulation of speech sounds3, as the open bite, the cross bite and the deep bite6. Moreover, the breastfeeding offers less  INTRODUCTION


METHODS
It was performed a transversal, descriptive and comparative study, characterized by convenience sample and made from two groups: pregnant women (n=36) and other of postpartum women (n=80).The research was done between June and August 2012, in the Grupo de Gestantes do Ambulatório de Ginecologia e Obstetrícia (Pregnant Women's Group of Gynecology and Obstetrics Clinic) and in the Alojamento Conjunto da Maternidade Mário Totta (Mario Totta's Rooming Maternity), both of them belonging to the Santa Clara's Hospital from the Complexo Hospitalar Santa Casa de Misericórdia de Porto Alegre.This research was approved by the Research's Ethics Commitee / Santa Casa # 23355.
The city of Porto Alegre, in which the research was conducted, has a population of 1.409.351.In 2010 there was a total of 17.359 newborn in hospitals -per mother's residence place 16 .The hospital in which the research was conducted presented 3.762 child-births, 22% of the total in the city of Porto Alegre 17 .
In order to participate in the research, the person should have fulfilled the inclusion and exclusion criteria.The inclusion criteria for the pregnant women's group were: perform prenatal in the clinic in above, be in the Pregnant Women's Group offered in the place, and no having participated in the Pregnant Women's Orientation Group with the Speech Language Pathology.The inclusion criteria for the postpartum women's group were: being in a room in the maternity above, must hold exclusive breastfeeding and being in the post-partum for 12 to 48 hours.In both groups it was demanded the signing of the free and informed term of consent and, in case the person was a minor, the responsible for her should also have signed.
It was excluded the postpartum women that could not breastfeed, due to HIV or for being a drug user or the ones with the newborn baby in the Neonatal Intensive Care Unit.
The gathering was made in the following way: for the pregnant women's group, before the beginning of the pregnant women's group, it was presented the research and the consent term.After this, it was given the identification card and the questionnaire elaborated for the research.The questionnaire addressed questions such as: instructions related to the breastfeeding, mammary cleft, and weak milk, relation between the stomatognathic system and the breastfeeding, deleterious oral habits, contraindications to breastfeeding and kinds of nipples.It was explained the clear way to fulfill the questionnaire.Afterwards, they were oriented about the risk to dental cavities, when associated to a correct oral hygiene 6,8 , and to oral diseases and infections 6 .
In Brazil, it can be observed an increasing in the breastfeeding-only rate, but it is still below the recommended by the World Health Organization.The data from the II Pesquisa Nacional de Prevalência de Aleitamento Materno nas Capitais Brasileiras e Distrito Federal (2nd National Research of breastfeeding prevalence in the Brazilian capitals and Federal District) show that the breastfeeding prevalence in children under 6 years old is around 41% of breastfeeding-only 9 .This value delimits to "fair" in the classification related to the breastfeeding-only practice.The values from the indicator for fewer than 6 months old children are between 50% and 89% to be classified as "good" and over 90% to be classified as "very good" 10 .Reflecting on these indicators, you should invest in promoting both the prenatally as in puerperal breastfeeding.
It is on the gestational period that it comes the wish to breastfeed.The motivation is what permeates the mother's decision to breastfeed.It takes in consideration the social context and life experience, for the woman to decide to do it 11 .
In the first weeks of breastfeeding, it may appear difficulties in doing it 2 .Many times, the women do not know the context of breastfeeding or she is still not ready for doing such thing, which makes them more vulnerable to present difficulties and doubts during the process.
The health professional has an important role in preventing and intervening in the difficulties related to breastfeeding, which demands knowledge and specific abilities 12 .The mother should be helped to live the breastfeeding in a healthier way, more integrated with herself, a fact that, certainly, will be useful for her to feed her newborn child in every way: biologic, sensorial and psychic 13 .Any professional, engaged in the incentive of the breastfeeding (audiologist, dentist, doctor, nurse, and others) may be the responsible for developing the "empowerment" of the woman related to breastfeeding.Everyone should raise awareness about the conditions in which the stomatognathic system's structure development takes place in the infancy 14,15 .
Based on this thematic context of the breastfeeding , this research aimed to identify and describe which are the doubts and difficulties from the pregnant and postpartum women related to breastfeeding, besides comparing them in the prenatal and postpartum periods.It is believed that the data may facilitate the intervention to incentive the breastfeeding practice, seeking the well-being and health of the woman and the newborn baby.
The data gathered from the screening of the records and the research made with the questionnaire created a database in a Microsoft Excel's spread sheet.The variables were analyzed by associations between the answers of the groups using the Chi-square test, Fisher's exact and Student's t.It was adopted as a trust interval 95%.

RESULTS
The overall sample was made from 116 women, being 36 of them pregnant women and 80 'postpartum women.The average age was 27 (± 6,2) years old in the postpartum women and absolute average of 25 (± 6,4) years old, with p=0,117 , by the Student's T Test.
It was observed, related to general knowledge related to breastfeeding, that the postpartum women presented better knowledge score (56,6%) when compared to the pregnant women (40,5%), being p = 0, 001.The questions from the knowledge evaluation instrument about breastfeeding that presented meaningful difference when compared between both groups were: facial growth benefit (p= 0,001); baby's speech development benefit (p=0,007); hearing problems prevention benefit (p=0,004); the size of the nipple helping the breastfeeding (p= 0,003) and the possibility of inverted nipple or plain nipple women to breastfeed (p=0,001) (Chart 1) breastfeeding as a lecture with a free discussion after it.During this moment it was discussed the doubts of the questionnaire, the position to breastfeed, how to hold the breast, breast care, and benefits of the breastfeeding for the newborn baby as well as for the mother, deleterious habits, and development of the orofacial structures.
For the postpartum women's group, it was made a screening, in the maternity, to verify the conditions that the parturient was by the medical reports and to check information that could include or exclude them from the research -number of the records, age, result from the HIV test, drug user or not, being breastfeeding or not -and from the newborn baby -number of records, age, where he was located (ICU or in the same room as the mother) and clinical intercurrences.After identifying the candidates for the research, they were invited to participate in the research and to sign the consent term.The questionnaire was done orally (the researcher read the questions to the mother).The questionnaire addressed the same instruments of the evaluation used for the pregnant women, added the questions about: how to hold the newborn baby, presence of clefts, amount of milk, mammary pain, relation between the kind of nipple and the moment of the breastfeeding, somnolence of the newborn baby.To end it, it was given information about breastfeeding and it was made interventions, when needed, in order to help the postpartum woman with her difficulties.
In order to associate the age change with the knowledge about breastfeeding (figure 1) it was found that in the postpartum women group, the older the woman, the more she knew about it (r= 0,283; p=0,011).In the pregnant women groups this association was not made (r= 0, 017; p=0,920).
When both groups were questioned about the doubts related to the breastfeeding in general, in the group of postpartum women 8,9% (n=7) and in the group of pregnant women 34,3% (n=12) reported having doubts related to breastfeeding.The number of doubts in the pregnant women group (n=12) is significantly bigger than the postpartum group (n=7) (p=0,002).The main doubts reported by the pregnant women were related to the milk production, colostrum in the postpartum period 11% (n=4), and the milk secretion release during pregnancy 8,3% (n=3).
Related to the exclusive analyzes from the postpartum group (n=80), 36,3% (n=29) presented complaints/difficulties during the first hours of presented more doubts than the postpartum women (p=0,002).Probably, it happened due to the fact that the postpartum women completed her prenatal and had received the support and orientation of many health professionals during the breastfeeding.
There is still an influence from the place of study being in a Children-Friendly Hospital (Hospital Amigo da Criança), which propose changes in the maternity routine, suggesting all their professionals to be able to assist and be able to help the women about breastfeeding [19][20][21] .
It can be observed that the pregnant women had more doubts related to Speech Language Pathology (benefits for the facial growth, for the speech development, for the prevention of hearing problems).The Speech Language Pathology team needs to be inserted in the actions since the prenatal, making the women to widen her view of these aspects 18,19 .A multiprofessional team that contemplates the needs of the pregnant women and, in the future, of the postpartum women, will enrich the actions to promote the exclusive breastfeeding and its benefits.The clearer and more complete is the clarification of all possible contributions that the act The chart 2 shows the absolute frequency of the affirmative answers in the questions related only to the postpartum women group.When questioned about the factors that may harm the breastfeeding, the most common answers related to harm were the following: the newborn baby not holding the areola; having "clefts"; not having milk or having little milk; having pain in the breasts; the newborn baby sleeping while is breastfed.(chart2)

DISCUSSION
The current cultural scenery related to the maternity delimits the idea that the women is the main responsible for the child care, as she is the one who gets pregnant and breastfeed 18 .In this context, it is a role of the health professionals to demystify this thought and pursue actions that promote the breastfeeding and to encourage the support to the family during pregnancy and breastfeeding, as the family is essential to the woman during the postpartum period 19 .
In the study, it was observed that the postpartum women presented more knowledge about breastfeeding (P= <0,001) and the pregnant women more than one child needs to be different 24 .The primiparous women has a great vulnerability factor which is the inexperience and, facing difficulties, it may lead to the early wean 25 .
The present study shows another piece of information that should receive attention from the health professionals: the postpartum women's age.The younger the women are, less knowledge about breastfeeding she has.In Brazil, there are reports about fewer manifestations of breastfeeding on teenagers and young women 26 .In this context, the low maternal age is related to the shorter period of breastfeeding, perhaps motivated by many difficulties that the non-planned pregnancy may bring 26,27 .Educate and organize this group of teen and young women for them not to be unmotivated and quit breastfeeding becomes a challenge to the professionals engaged in this theme.
The postpartum women face a period of hard handling during the first hours of breastfeeding due to the physical difficulties on their breasts, like the engorged breasts, pain and nipple trauma.Any of these factors may consist in a physical obstruction with a negative repercussion on the breastfeeding, leading to a break in the breastfeeding.Thus, the women may avoid breastfeeding of the newborn child 12,23,26 . of breastfeeding brings the mother and her son, the bigger will be the number of women doing it 19,20 .
Analyzing the kind of doubts in both groups, it can be observed that there is a distinction between pregnant women and postpartum women.During pregnancy, there are doubts about the milk production and colostrum in the postpartum and to the milk secretion during pregnancy.During the postpartum period, the doubts are bout the time waited to breastfeed and the time between breast feedings.It is important to highlight that there should be orientation during the pregnancy as well as during the postpartum period, because the presence of doubts is a reality and the knowledge about breastfeeding should be built from the different realities found.Based on that, the professional needs to contextualize their orientations and aim them to the existent demand 22. Another important data related to the complaints is that the primiparous women had more complaints and difficulties than the women that had already had a child.In a study made in the city of São Paulo, it was observed that when the women had already breastfed and presented a well-succeeded breastfeeding were willing to only breastfeed their next children and for a longer time 23 .Thus, it can be considered that the strategy with the postpartum primiparous women and the postpartum women with Tabela 2 -Frequência de respostas de questões específicas para puérperas (primiparous, teen, or young women), voiding the early wean.
There is a need from the health professional to guide the women related to the prevention and promotion of the breastfeeding, answering the doubts during the pregnancy, helping the pregnant women to have good conditions to breastfeed, and to educate them about the natural feeding, getting to the postpartum period more self-assured and incentivized to keep only breastfeeding until the sixth month postpartum.

ACKNOWLEDGEMENT
To the dedication and technical help from the professors Sheila Almeida and Marcia Maahs.
To the contribution with the scientific review from the professor Fabiana de Oliveira and Angelica Maria G Fritscher.
To the help in collecting the data from the scholar Natasha Ramos.
To the tchnical statistical ssistance from Ceres Oliveira.
It is essential for the women to feel properly assisted on their doubts and difficulties, so they may take on the role of mother and the breast feeder to the child more self-assured 26 .Due to these, the care team should be prepared to the handling of the postpartum women, in order to help her face the first difficulties they may face, to avoid the early wean [28][29][30] .

CONCLUSIONS
Based on the results obtained, there may be a better understanding of the difficulties and doubts that the postpartum and the pregnant women show.Postpartum women show a greater knowledge related to the breastfeeding than the pregnant women, in the studied sample.Pregnant women show more doubts related to breastfeeding that the postpartum women interviewed.

Figure 1 -
Figure 1 -Association between the age and the knowledge related to breastfeeding (Postpartum and pregnant group)