ROOMING-IN PRACTICES AND SATISFACTION WITH CARE ACCORDING TO DISCHARGE ON EXCLUSIVE BREASTFEEDING

ABSTRACT Objective: to describe the practices that favor breastfeeding performed in the Rooming-In area and satisfaction with the care received according to discharge on exclusive breastfeeding. Method: a quantitative study conducted between July 2020 and September 2021 in a maternity teaching hospital from southern Brazil; a total of 756 puerperal women participated by means of an online questionnaire 20 days after hospital discharge. The data were analyzed in a descriptive way with absolute and relative frequencies, and the chi-square test was applied to verify any statistical difference according to the “discharge on exclusive breastfeeding” outcome. Results: the prevalence of discharge on exclusive breastfeeding was 85.0% and the practices that presented and association with the outcome were guidelines regarding the breastfeeding readiness signs (69.0% versus 57.5%), correct position and latch (94.1% versus 86.7%), free demand (79.2% versus 69.0%), exclusive breastfeeding until the sixth month of life and complemented until two years of age (77.9% versus 67.3%); and the practice of not offering other milk during hospitalization (88.5% versus 17.1%). Satisfaction with the care received was high (95.0%) and presented no association with the outcome of “discharge on exclusive breastfeeding”. Conclusion: most of the women treated had access to the practices that favor breastfeeding, and education in health exerted a positive impact on exclusive breastfeeding at hospital discharge.


INTRODUCTION
In addition to being unique and unequaled, breast milk is the ideal food alternative for children, as it is completely adapted to their needs in the first years of life.The benefits of breastfeeding have direct or indirect repercussions for the woman and the infant.For the woman who breastfeeds, it reduces the risk of developing breast and ovarian cancer; and in the individual's later life, it reduces the occurrence of chronic diseases such as hypertension, diabetes and obesity.In addition to the aforementioned physical factors, breastfeeding also promotes children's and mothers' mental health by strengthening the bond between them [1][2] .
Breastfeeding protection, promotion and support have been a globally relevant strategy to improve children's and women's health conditions.For this reason, it is extremely important to monitor the indicators and investigating breastfeeding, as it exerts a direct impact on the maternal and child morbidity and mortality patterns 3 .National and international strategies address the topic, such as the Sustainable Development Goals (SDGs); for Brazil, the target is to reduce the maternal mortality rate to a maximum of 30 deaths per 100,000 live births and the neonatal mortality rate (less than 28 days after birth) to 5 per 1,000 live births by 2030 [4][5] .
In view of this, in recent decades the world has observed an increase in the breastfeeding rates; however, a study that evaluated breastfeeding in the 21 st century in several countries, identified that only 36% of all children are exclusively breastfed until the sixth month of life 3 .In Brazilian maternity hospitals, a systematic review identified a variation between 16% and 56% in the prevalence of breastfeeding in the first hour after birth 6 , and a study conducted in Pernambuco found a median of 60.8 days in the prevalence of exclusive breastfeeding and 182.5 days for its total duration 7 .When taking into account the recommendation by the World Health Organization (WHO) and the Brazilian Ministry of Health that exclusive breastfeeding be performed until the sixth month of life and complemented until two years of age, the data show the need for strategies to strengthen breastfeeding.
In this context, there is the Baby-Friendly Hospital Initiative (BFHI) created in 1990 by the WHO and the United Nations Children's Fund (UNICEF), in response to the call to action of the Innocenti Declaration, as a set of targets aimed at rescuing women's right to practice successful breastfeeding 8 .Brazil was one of the 12 countries initially chosen to implement the BFHI, formalizing the commitment to making the "Ten Steps to Successful Breastfeeding" a reality in Brazilian maternity hospitals.Currently, the country has more than 300 hospitals accredited as "Baby-Friendly", and the BFHI is one of the components included in the National Policy for Breastfeeding Promotion, Protection and Support 9 .
Implementation of the criteria of this policy allows guiding humanized assistance to women, newborns and fathers/companions.This policy promotes breastfeeding from prenatal care, during labor and throughout the hospitalization period, seeking to empower women and fathers/companions to manage breastfeeding and its possible difficulties, so as to prepare them for a safe discharge process 1 .
As foreseen in step seven of the BFHI "Ten Steps to Successful Breastfeeding", hospitalization in the Rooming-In area allows mothers and newborns to be together 24 hours a day and throughout the hospitalization period, which represents many benefits, being a strategy of utmost importance for a safer life beginning and early bonding 10 .
Implementation of the BFHI has been the objective of various studies that found higher proportions of breastfeeding in the first hour of life and exclusive breastfeeding at discharge 6,[11][12] .Thus, identifying the prevalence as well as promotion, protection and support strategies for breastfeeding in health institutions from different regions of the country will allow developing new actions related to public policies aimed at the maternal-child population and ratify already existing actions, especially with regard to the BFHI.In addition to that, it is fundamental to disseminate and discuss this topic both in the scientific community and in the general population 6 .

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Although several factors have been identified as influential in the success of exclusive breastfeeding, satisfaction with the care received emerges as a crucial factor to be explored.In this sense, a descriptive cross-sectional study carried out with 231 puerperal women and their newborns hospitalized at a Rooming-In are in southern Brazil identified high satisfaction with the care provided (97.8%), reflecting the quality of breastfeeding support 13 .It is important to highlight the relevance of new studies on satisfaction since, with them, there is the possibility of identifying areas for improvement, monitoring changes over time, and providing a basis for the formulation of health policies and guidelines.This research can play a key role in the search for a service that is increasingly focused on the needs of puerperal women, promoting their satisfaction and contributing to a better experience with breastfeeding.
Thus, this study was conducted based on the following research questions: Which is the prevalence of discharge on exclusive breastfeeding in Rooming-In?Which practices that favor breastfeeding according to the "Ten Steps to Successful Breastfeeding" are performed in the Rooming-In area?How satisfied are women with the care received?Is there an association between performing practices that favor breastfeeding and satisfaction with discharge on exclusive breastfeeding?The study objective was to describe the practices that favor breastfeeding performed in the Rooming-In area and satisfaction with the care received according to discharge on exclusive breastfeeding.

METHOD
This is a cross-sectional and descriptive study, carried out in a virtual environment and based on the BFHI "Ten Steps to Successful Breastfeeding", regarding fulfillment of the assumptions of this policy in the Rooming-In area.
The study took place in the maternity of a teaching hospital from southern Brazil, which has held the Baby-Friendly Hospital title for 26 years and is a reference for the care of high-risk pregnancies.The maternity hospital under study has obstetric emergency services, an obstetric center, a gynecological unit, Rooming-In and a neonatal unit, the latter with intensive care beds.At the data collection moment, the Rooming-In area had 17 beds devoted to puerperal women and six beds for high-risk pregnant women.During the hospitalization, the women, newborns the companions receive support from an interdisciplinary team in all the maternity services.The maternity hospital also has a Nursing team responsible for the Breastfeeding Promotion Center that monitors and reinforces the guidelines related to breastfeeding and breast care, in addition to offering practical help at the time of care.In the Rooming-In area, the discharge routine for women who have had vaginal deliveries occurs 24 hours after birth and.for those who have undergone C-sections, only after 48 hours.
The inclusion criteria for participation in the study were women aged at least 18 years old and who had given birth to their children in the maternity hospital under study.The women excluded were the mothers who did not have their children admitted to the Rooming-In area, that is, those whose children were hospitalized the Neonatal Unit, as well as women who did not provide a telephone number for contacts.
The participants were contacted via a message app between 24 and 48 hours after discharge from the maternity hospital and followed-up with remote care by the Breastfeeding Promotion Center staff for 15 to 20 days.These appointments consisted of the professionals' initial contact, making themselves available to help with questions related to breastfeeding.At the end of this period, the women were invited to participate in the research, at which time they were sent a questionnaire to be answered in Google Forms ® that contained 19 questions: 14 multiple choice ones with more than one answer option, and four open questions.

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In this article, the outcome variable investigated was "discharge on exclusive breastfeeding" and the exposure variables corresponded to data on prenatal care (place and information on breastfeeding received); data related to breastfeeding practices and guidance in the Rooming-In area (breastfeeding readiness signs; correct position and latch; free demand; exclusive breastfeeding until the sixth month of life and complemented until two years of age); how to perform the milking procedure; use of baby bottles, artificial nipples and pacifiers; place to receive help regarding breastfeeding after hospital discharge; offer of other milk during hospitalization); and satisfaction with the care received at the maternity hospital and with the follow-up of the service via a message app after hospital discharge by means of a five-point Likert-type scale.All variables were categorized in a nominal qualitative way (yes or no), and the Likert scale variables were categorized into yes (very satisfied and satisfied) and no (neutral, dissatisfied, very dissatisfied).Data collection took place between July 2020 and September 2021, during the COVID-19 pandemic.
The maternity hospital serves a mean of 201 births per month (data referring to 2021).During the study period there were 3,080 births and, of these,2,455 women met the inclusion and exclusion criteria; they were contacted via a message app, followed by the questionnaire, a number that corresponded to 79.7% of the women treated in the maternity hospital.The sample was by convenience and, from the total number of women who received the questionnaire, answers were obtained from 756 participants, a response percentage of 30.8% among the eligible women, and 24.5% representativeness when compared to the total number of women treated during the period (Figure 1).The number of participants in this research is considered significant, taking into account that the return rates of surveys sent by email are close to 25%-30%, especially when no participation reminders are sent 14 .
The data collected were organized in an Excel spreadsheet and analyzed in the Stata statistical software, version 13.In the descriptive analysis, the absolute and relative frequencies were calculated, followed by application of the z-test to identify a possible statistical difference between the proportions.In the analytical stage, the absolute and relative frequencies of the outcome variable were calculated according to the exposure variables, with application of the chi-square test.p-values<0.05 were considered to assume statistical differences.
The research respected the ethical issues in terms of Resolution No. 466/2012 of the National Health Council, with due authorization from the participating institution, and was approved by a Committee of Ethics in research with Human Beings.For being a virtual environment research study, it respected circular letter No. 2/2021 of the National Research Ethics Commission (Comissão Nacional de Ética em Pesquisa, CONEP), which seeks to ensure the research participants' protection, safety and rights.In the ethical review, waiver of the Free and Informed Consent Form (FICF) was requested and accepted for the non-use of personal data; only data on the assistance provided were collected.The invitation to participate was made during the remote appointments, via a message app and by the Breastfeeding Promotion Center team.Answering the online questionnaire was considered as agreement to take part in the research.

RESULTS
The study participants were 756 women who gave birth to their children in the maternity hospital researched, and the prevalence of discharge to exclusive breastfeeding was 85.0%.In the participants' characterization, the majority had prenatal care in the public service (91.0%) and the minority received guidelines on breastfeeding during prenatal care (39.7%).The investigation of discharge on exclusive breastfeeding according to these variables presented no statistical difference (Table 1).Regarding the practices performed in the Rooming-In area, six out of seven practices aimed at identifying, guiding or explaining breastfeeding were received by most of the participating women and presented a statistical difference.The following stand out among these practices: guidance on the infant's correct position and latch (93.0%), place to receive help regarding breastfeeding after 7/15 hospital discharge (81.5%), free demand (77.7%), exclusive breastfeeding until the sixth month of life and complemented until two years of age (76.3%), milking (75.5%), and the signs indicating that the infant wants to breastfeed (67.3%).Most of the women did not offer milk other their breast milk to their newborns (72.2%).Half of the participants were instructed about the risk of using baby bottles, artificial nipples and pacifiers for breastfeeding (52.7%), but this percentage did not reach statistical difference in the analysis with the outcome (Table 2).
Discharge on exclusive breastfeeding was assessed according to the practices performed in Rooming-In.There was a statistical difference, with higher prevalence of discharge on exclusive breastfeeding, in the guidelines regarding the breastfeeding readiness signs (69.0%versus 57.5%), correct position and latch (94.1% versus 86.7%), free demand (79.2% versus 69.0%), and exclusive breastfeeding until the sixth month of life and complemented until two years of age (77.9% versus 67.3%).The practice of offering milk other than the woman's to the newborn was associated with lower prevalence of discharge on exclusive breastfeeding (17.1% versus 88.5%) (Table 2).Satisfaction with the care received in the maternity hospital under study was high, including the breastfeeding service and follow-up care via a message app after hospital discharge: 95.0% of the women answered that they were satisfied or very satisfied.When investigating the satisfaction level, no association was found with the "discharge on exclusive breastfeeding" outcome (Table 3).

DISCUSSION
The results of this study show high prevalence of discharge on exclusive breastfeeding and a positive evaluation of the practices performed in the Rooming-In for breastfeeding promotion in a Baby-Friendly hospital, which remained high even in the presence of a pandemic with strong social, economic, cultural and political impacts for the entire world population.When comparing these results with international studies, a survey conducted in Italy found similar results that showed the effectiveness of BFHI on discharge on breastfeeding with prevalence higher than 80% in the maternity hospitals that were part of this initiative, similarly, with data collected during the COVID-19 pandemic 11 .
Indicators of exclusive breastfeeding are used to assess child growth and development and the level of development of populations around the world.There are targets to improve this indicator, among them the Global Nutrition Targets of the United Nations 2030 Agenda, which aims at achieving a 50% rate of exclusive breastfeeding in the first six months of life by 2025, reaching 70% by 2030 15 .In Brazil, according to data from the National Survey on Child Nutrition (Estudo Nacional de Alimentação e Nutrição Infantil, ENANI) published in 2021, the prevalence of exclusive breastfeeding among children under six months of age was 45.8%, and 54.3% in the South region 16 .These are numbers that show the importance of public policies for the maintenance and increase in the indicators of discharge on exclusive breastfeeding, an imperative factor for its continuity.
One of the challenges imposed, especially at the beginning of the COVID-19 pandemic and when there was no precise information about severity of the disease symptoms in newborns, about the possibility of vertical transmission 17 or during breastfeeding, was not to separate mothers and newborns in maternity hospitals.In Portugal, only one-third of the hospitals strengthened the Rooming-In measures and 6.0% of the hospitals recommended formula feeding for COVID-19-positive mothers 18 .
Maintenance of the mother-newborn dyad in the Rooming-In area at the maternity hospital under study during the pandemic remained an important factor for breastfeeding promotion and encouragement, a practice that may have collaborated with the success of discharge on exclusive breastfeeding.In the Rooming-In system, newborns sleep better and cry less because of proximity 9/15 to their mother; breastfeeding is well established and continues for longer periods of time with rapid weight gain; breastfeeding is guided by the infant's demand and is better established when the newborn is nearby; it helps with milk let-down; women feel more confident in caring for their babies; and it helps with bonding 19 .
The practice of separating newborns from SARS-CoV-2 positive women was evaluated in a study conducted in the United States and was associated with shorter duration of any form of breastfeeding or with other adverse effects related to breastfeeding up to one month after discharge from the hospital 20 .The knowledge production at the beginning of the pandemic identified in a scoping review conducted in April 2020 already recommended breastfeeding promotion, especially considering the immunization benefits for newborns 21 .
Also in the Rooming-In hospitalization context, the presence of a companion was not allowed in the researched institution during the pandemic, except in exceptional cases such as twins or any clinical condition of the mother that prevented her from being alone with the newborn.It is known that the presence of parents and/or family members during the assistance provided in maternity hospitals is a unique opportunity to establish an education and health relationship, at which time guidelines are provided on the care to be offered to the newborn, with the care in charge of the parents and supervised by the team, assisted when necessary, and with a focus on guidance on breastfeeding.
Most of the participants attended prenatal care in the public health network, receiving care both in Basic Health Units (BHUs) and in the researched hospital itself.Regarding the guidelines provided during prenatal care, only one out of four participants received guidance on breastfeeding.Although these results have not shown any significant difference in discharge on exclusive breastfeeding, another study, also conducted in Brazil, ratified the importance of educational actions on breastfeeding during prenatal care, by allowing sharing knowledge among pregnant women and the construction of greater knowledge about breastfeeding 22 .
The impact of the guidance provided during prenatal care and the assistance provided in public and private hospitals has been proved in international studies.A survey conducted in India showed greater success in the exclusive breastfeeding rates as well as in early breastfeeding initiation with the guidelines received in prenatal care 23 .In Hong Kong, a study identified a higher rate of exclusive breastfeeding in the six months of life of infants born in public hospitals, as well as a higher rate of adequate knowledge about breastfeeding in the evaluation of the professionals 24 .
As for practices that favor breastfeeding in the Rooming-In area and that are part of the "Ten Steps to Successful Breastfeeding", the multiprofessional team demonstrated involvement both in instructing mothers on the infants' correct positioning and latch on the breast, as well as in identifying the readiness signs indicating that the newborn wants to breastfeed.However, guidelines on the risks of using baby bottles, artificial nipples, pacifiers and the harms they can do to breastfeeding were only recalled by half of the participants.As recommended by the BFHI, non-use of these accessories is noticed in the study locus; however, as it is a habit linked to cultural issues, it is important that health professionals warn mothers and families, especially regarding the use of pacifiers, about the negative interference to infants' health and breastfeeding 25 .
Other benefits of implementing the BFHI as a public policy have been proved in several studies and show the importance of the Rooming-In team's involvement, as well as of breastfeeding support services during hospitalization 22,24 .In Germany, high rates of exclusive breastfeeding promotion during hospitalization and at hospital discharge were found in hospitals that followed the "Ten Steps to Successful Breastfeeding" proposed by the BFHI 12 .A study in Shanghai, China, found that increased breastfeeding support during hospitalization resulted in higher rates of discharge on exclusive breastfeeding, as well as of breastfeeding in the six months after birth 26 .

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When investigating associations with the practices carried out in the Rooming-In, the puerperal women who did not receive guidelines had lower prevalence values of exclusive breastfeeding at hospital discharge.This result corroborates other studies developed in hospitals and maternity hospitals from Korea and China, where the presence of trained professionals with time to provide guidelines resulted in a positive impact on the rates of discharge on exclusive breastfeeding [27][28] .
Another association found was the supply of milk other than the mother's during the Rooming-In stay, with lower prevalence of discharge on exclusive breastfeeding, although there was no significant difference in supply among the women surveyed.This result was also revealed in a previous study conducted at hospitals in the state of São Paulo, Brazil, which showed a two-fold reduction in the chances of breastfeeding at six months of age when formula was offered in the maternity hospital 29 .Among the reasons for offering formula milk reported by the mothers, a quantitative study conducted in the municipality of Porto Alegre (southern Brazil) with women receiving lactation consultancy services identified as causes the difficulty in the breastfeeding technique, breast fissures, low production or late lactation 25 .It is known that the offer of formula milk is a practice found in many maternity hospitals, but such offer should be restricted to cases with clinical indication, as this is one of the aspects that most contributes to early weaning 29 .Satisfaction with the care received in the Rooming-In area was high, which shows the team's commitment to the quality of the assistance provided in the maternity hospital.The high degree of satisfaction found in this study shows that mothers had a positive experience during hospitalization, which leads to better health outcomes and success regarding breastfeeding, in agreement with results found in Italy 30 .In Finland, a study from a mothers' perspective showed a positive impact of the actions developed in the Rooming-In area after adherence to the BFHI in supporting breastfeeding 31 .
Continuity of the care provided after hospital discharge has proved to be an important resource for breastfeeding promotion and encouragement, by allowing monitoring and support through possible complications or doubts related to the breastfeeding process, especially in the first days after birth 32 .Thus, in the pandemic context, Telehealth has been and continues to be an important strategic tool to provide safer and good quality health assistance for pregnant and puerperal women 33 .
It is worth noting that breastfeeding success is associated with factors such as Rooming-In, a favorable environment, qualified professionals, and bonding between professionals, women and families, among others.On the other hand, the COVID-19 pandemic exerted a significant impact on the dynamics of maternity-related health services, which resulted in access barriers and difficulties in prenatal, delivery and postpartum follow-up.In addition to that, the environmental and behavioral changes resulting from the pandemic also exerted impacts on the quality of the services provided 34 .
As a limitation in conducting this study, the convenience sample is acknowledged, which implies a cautious data analysis due to the generalization impossibility; in addition, data collection was carried out between 15 and 20 days after hospital discharge, which may lead to memory bias in the participants in relation to what happened during hospitalization; finally, the impossibility of an inferential analysis due to the absence of socioeconomic and demographic data of the study participants.

CONCLUSION
The results obtained in this study identified 85.0% prevalence of discharge on breastfeeding in the Rooming-In area and a positive impact of practices that favor breastfeeding, with higher prevalence of discharge on breastfeeding among the women who received guidelines on the infants' latch and position, identification of the breastfeeding readiness signs and the importance of exclusive breastfeeding until the sixth month of life and complementary breastfeeding until the age of two years old, as well as of free-demand breastfeeding.In contrast, the provision of other milk during hospitalization had lower prevalence of exclusive breastfeeding at hospital discharge.The results show a positive impact 11/15 of the health education activities on exclusive breastfeeding at hospital discharge, mainly regarding the guidelines, although there is a need to adopt practices that contribute to reducing the use of milk formulas without indication.
It is reiterated that, in the researched institution and even with the prohibition of companions in the Rooming-In area during the pandemic, a high percentage of discharge on exclusive breastfeeding was found.In addition to that, the high women's high levels of satisfaction with the service provided during hospitalization in the maternity hospital, as well as with the follow-up after discharge, show the degree of excellence of the care provided.These results are evidence of the team's support and commitment to encouraging and promoting exclusive breastfeeding.
In the constant search for knowledge construction, this study portrays how care quality is preserved even in the COVID-19 pandemic period and the introduction of new technology in this maternity hospital: post-discharge support in breastfeeding by means of Telehealth was approved by the women.It also highlights the importance of well-consolidated policies such as the BFHI, capable of overcoming moments of crisis and everything that may interfere with the work dynamics inside a maternity hospital, in adverse situations.
It is hoped that this study will contribute by encouraging other professionals who work in the pregnancy-puerperal period to protect, promote and support breastfeeding, as improving the results requires the commitment and involvement of the entire health team and hospital managers, in order to qualify assistance and promote the health of mothers and infants alike.
It is also suggested to develop studies that can provide health professionals with tools to devise effective strategies with these dyads, in order to promote breastfeeding in the maternity hospital and solve problems or complications that may arise at this early stage, including milk formula supply.The results of this study also show the importance of conducting assessments in hospitals and maternity hospitals to provide greater adherence and compliance with all the BFHI stages about breastfeeding.

Figure 1 -
Figure 1 -Selection of the participants: women treated in a teaching maternity hospital from southern Brazil.2020-2021 (n=756).

Table 1 -
Diverse information on prenatal care according to discharge on exclusive breastfeeding among women treated in a teaching maternity hospital from southern Brazil.2020-2021 (n=756).

Table 2 -
Practices performed in the Rooming-In area as per the BFHI "Ten Steps to Successful Breastfeeding" according to discharge on exclusive breastfeeding among women treated in a teaching maternity hospital from southern Brazil.2020-2021 (n=756).

Table 3 -
Satisfaction with the care received according to discharge on exclusive breastfeeding among women treated in a teaching maternity hospital from southern Brazil.2020-2021 (n=756).