Introduction

Breastfeeding is a natural strategy of bonding, affection, protection and nutrition of children, constituting the most sensitive, economical and effective intervention to reduce infant morbidity and mortality and promote comprehensive health of the mother-baby binomial.¹It represents an act of human relationship inserted in culture and submitted to the social sphere, which transcends the nutritional aspect and requires the support of significant people and government programs of incentive.^2-3

Breastfeeding mothers need active and emotional support as well as accurate information to feel confident and prepared for this process. However, the support offered by health professionals is often incipient.¹ Given this fragility and despite all the evidence in favor of breastfeeding, breastfeeding rates in Brazil and worldwide have not reached the levels recommended by the World Health Organization, which advocates a minimum rate of 50% of exclusive breastfeeding in the first six months of life.⁴

Factors that may contribute to the non-adherence to breastfeeding are extrinsic and intrinsic to the mother and baby, such as issues related to anatomical aspects of nipples, popular beliefs about breast milk and the process of breastfeeding, breast engorgement, fear and pain. Such issues may be addressed through the enhancement of the mother's knowledge prior to the breastfeeding practice.¹Cultural, sociodemographic, biological and care factors have been identified as determining factors for early breastfeeding, especially regarding the introduction of other foods, unnecessary in the first semester of life, with negative effects on breastfeeding success, bearing in mind that breast milk contains all the necessary nutritional components to promote healthy nutrition up to six months of life.⁵

The difficulties in stimulating and achieving effective breastfeeding, therefore, have raised the concern of world health agencies involved in the promotion and encouragement of breastfeeding. These agencies are essential for the investment in the development of programs and strategies to maximize this practice and, consequently, improve breastfeeding compliance rates.⁶

In the meantime, it is understood that educational actions aimed at pregnant women and postpartum women lead to increased maternal self-efficacy for breastfeeding adherence, and the nursing team has an important role in transmitting information to mothers before, during and after the birth of the baby, to instrumentalize them and favor the act of breastfeeding.^7-8

Primiparous pregnant women often have difficulties with breastfeeding, which associated with ineffective prenatal care and gaps in the guidance provided during hospitalization and during the care process contribute to non-adherence to breastfeeding.^9-10 Nursing care is essential to encouraging and supporting breastfeeding, as it can contribute to the reduction of infant morbidity and mortality and early weaning.^11-12

In view of this problem, the following research question was raised: How is the knowledge of puerperal women characterized, based on breastfeeding guidelines? Thus, the objective was to identify the knowledge and analyze the process of guidance of mothers about breastfeeding.

Method

This is a descriptive, cross-sectional research with a quantitative approach, conducted in a high-complexity teaching hospital in the countryside of the state of Minas Gerais, with 220 beds. The maternity sector linked to the Unified Health System (SUS) has specifically 24 beds for gynecology and obstetrics, two isolation beds, nine pediatric beds and one nursing team that includes four nurses and 20 nursing professionals with technical education.

The population consisted of a convenience sample characterized by all mothers present in the maternity sector of the abovementioned hospital from December 2016 to June 2017, totaling 69 patients. The inclusion criteria were as follows: primiparous women, over 18 years old, approached after childbirth in the immediate postpartum phase. The exclusion criteria were mothers who had miscarriages or fetal deaths and who were emotionally weakened, under psychological follow-up.

A self-explanatory questionnaire was used to collect data. The instrument was adapted by the researchers with the authorization of the authors of the original study¹³ and consisted in three distinct steps. The first step covered the sociodemographic characterization of the mothers, through four questions regarding age, education, marital status and employment bond. The second characterized the process of guidance of mothers in the maternity ward, containing seven questions that covered the place where the guidelines were provided; the professional responsible for the guidance; consideration of the importance of guidelines for the success of the breastfeeding process in the perception of the puerperal women; guidance during stay in the hospital environment; level of confidence for breastfeeding; and satisfaction with the guidance process.

The third stage identified the knowledge of mothers about breastfeeding after receiving the instructions, verifying the understanding and retention of cognitive knowledge through nine questions that addressed the ideal time for the first breastfeeding; the correct position to breastfeed; the perception of correct breastfeeding; the correct latch onto the breast; beliefs; correct breastfeeding time; ideal time to change the breast during breastfeeding; knowledge about exclusive breastfeeding; and ideal age for the end of exclusive breastfeeding. The instruments were delivered to the mothers to be filled in the presence of the researcher, but without interference, avoiding bias in the filling.

Data were entered into an Excel® spreadsheet, double-validated, and then exported to the Statistical Package for the Social Sciences (SPSS), version 19.0, for Windows® for processing and analysis. The variables were analyzed according to descriptive statistics through absolute and percentage frequency distribution. The study was submitted to the Human Research Ethics Committee under Resolution 466/12 for appreciation, and approved under protocol 58913816.4.0000.5145. The participants were consulted regarding their interest and availability and they filled out the Informed Consent Form after being informed of all the particularities of the study, and after receiving assurance of the confidentiality and voluntary nature of their participation.

Results

First, the sociodemographic characterization of the participants is presented in Table 1.

Table1 - Sociodemographic characteristics of mothers present in the maternity ward of a hospital, Uberaba (MG), Brazil, 2017 (N = 69)

Variables	N	%
Age group, years
18-20	23	33.4
21-25	31	44.9
26-30	10	14.5
31-35	5	7.2
Schooling
Illiterate	0	0
Incomplete elementary school	5	7.2
Complete elementary school	3	4.3
Complete secondary school	43	62.3
Incomplete high school	14	20.3
Higher education	4	5.9
Marital status
Single	17	24.6
Married	21	30.4
Living together	31	45.0
Job bond
Technical level	35	50.8
Higher education level	2	2.9
Housewife	25	36.2
Unemployed	4	5.8
Student	3	4.3

The prevalent age range was 21 to 25 years (44.9%). Regarding education, 62.3% completed high school. There was predominance of the marital status "living together", with 45.0%, and regarding employment, 50.8% reported performing a job that required technical level.

The process of guidance on breastfeeding performed in the maternity from the perspective of the women is shown in Table 2, considering the questions number 1 to 3 (N = 69) (total puerperal women) and questions 4 to 6 (N = 41) (total puerperal women who were guided during pregnancy).

Table 2 - Characterization of the process of guidance of postpartum women, Uberaba (MG), Brazil, 2017

Variables ]]	n	%
1. Were you instructed about breastfeeding during pregnancy?
Yes	41	59.4
No	28	40.6
2. Where was this guidance given?
Nowhere	28	40.5
Basic Health Unit	8	11.5
Women's Health Care Center	4	5.7
Hospital	23	33.6
Friends/family	6	8.7
3. Which professional provided this guidance?
Friends/family	3	4.40
Physician	14	20.2
Nurse	22	32.0
Others	2	2.8
No one professional	28	40.6
4. Do you think that the guidelines offered were sufficient for your understanding?
Yes	21	51.3
No	20	48.7

5. Do you feel confident to breastfeed your baby after the guidance you received?
Yes	31	76.0
No	10	24.0
6. Are you satisfied with the guidelines you received?
Yes	31	76.0
No	10	24.0

Of the total of puerperal women, 59.4% received guidance; most of them (33.6%) received it during hospitalization, and predominantly from nurses (32.0%). Most mothers (51.3%) considered the guidelines were sufficient, and 76.0% felt confident and satisfied to breastfeed their baby after the received instructions.

Table 3 presents the characterization of the knowledge of the studied population about the breastfeeding process.

Table 3 - Characterization of the knowledge of the puerperal women present in the maternity ward of a hospital in the countryside of Minas Gerais about the breastfeeding practice, Uberaba (MG), Brazil, 2017 (N = 69)

Variables	N	%
When should you start breastfeeding?
Start time is not important	1	1.4
Within the first hour of life as soon as mother and baby are ready	60	87.0
When the baby feels like it	8	11.6
What should be the baby's position in relation to the mother at the moment of breastfeeding?
Baby's face facing breast with nose at nipple
Yes	36	52.2
No	33	47.8
Baby's body next to mother's
Yes	36	52.2
No	33	47.8
Twisted baby's neck
Yes	1	1.4
No	68	98.6
The baby is in a well-supported position
Yes	36	52.2
No	33	47.8
Baby with head and trunk aligned
Yes	43	62.3
No	26	37.7
Can you identify if your baby is breastfeeding correctly?
Yes	51	73.9
No	18	26.1
Correct statements regarding the signs of latch onto the breast
Baby's mouth is wide open
Yes	49	71
No	20	29
Baby latches only the nipple
Yes	10	14.5
No	59	85.5
The baby's chin touches the breast
Yes	30	30.4
No	48	69.6
The lower lip faces outwards
Yes	34	49.3
No	35	50.7
The baby's mother feels pain during breastfeeding
Yes	5	7.2
No	64	92.8
There is noise during breastfeeding
Yes	15	21.7
No	54	78.3
A mother may have weak milk
Yes	32	46.4
No	37	53.6
What is the correct breastfeeding time?
Until the baby does not want anymore	50	72.5
Ten minutes on each breast	11	15.9
Let the baby empty both breasts	4	5.8
The feeding ends when I want to stop	2	2.9
Nulo	2	2.9
You must offer the same breast at each breastfeeding time
Yes	3	4.3
No	66	95.7
You know what exclusive breastfeeding is
Yes	15	21.7
No	54	78.3
What is the recommended age for exclusive breastfeeding?
4 months	1	1.4
6 months	11	16
As long as the baby wants	2	2.9
While there is still milk	1	1.4
I don’t know	54	78.3

The mothers' knowledge about breastfeeding revealed that the majority of the mothers (87%) knew the ideal moment of the baby's first breastfeeding, 52.2% recognized which was the correct position to breastfeed the baby, 73.9% knew to identify if the latch was correct, 53.6% said that weak milk did not exist, 72.5% believed that the breastfeeding time should correspond to the time until which the baby no longer wanted to go on feeding, 95.7% of the mothers emphasized that the mother should not offer the same breast during breastfeeding, and 78.3% did not know what exclusive breastfeeding was.

Discussion

A considerable part of the participants (44.9%) had their first pregnancy between the ages 21 and 25, corroborating the age group in which the majority of Brazilian women become pregnant.¹⁴Women who become pregnant after 21 years of age, as evidenced in this research, enjoy greater psychological and emotional maturity, especially for the management of breastfeeding. In contrast, adolescent mothers are more likely to introduce other fluids during breastfeeding and abandon this process for a variety of reasons.^15-16

Regarding the educational level of the population, there was a predominance of complete high school and absence of illiteracy among pregnant women. This aspect positively interferes with the reception and interpretation of guidelines given in the maternity sector regarding the practice of breastfeeding.^16-17 Low education leads to the absorption of popular teachings and common sense, not always appropriate to the process of breastfeeding, cultivated by ancestors of the puerperal women and family culture, which may impair breastfeeding.^16,18

Most of the mothers in this study considered expressed as marital status the condition of living with partner or being married, pointing to the figure and the presence of the father as possible supports in the breastfeeding process. In line with this premise, a research found that single mothers found it difficult to practice breastfeeding in a harmonious way because of the physical and emotional distress they face when they feel alone in this process.^8,15

Most of the mothers reported having some employment bond. This reality is in agreement with a research conducted in Mamonas (MG), in which 51.51% of mothers worked outside the home.¹⁰ The strongest factor leading to early weaning has been the woman's return to work to assume her position as home administrator, negatively influencing breastfeeding.⁸

Characterizing the process of guidance about breastfeeding and the knowledge of mothers about the theme were the main goals of this study. In this sense, it was revealed that, although most of the mothers had received guidance about this practice, 40.6% indicated otherwise, ie, they had not received such instructions, thus exposing a gap in both primary health care and tertiary level care.

It is noteworthy that most of the mothers who felt instructed received information and assistance about this practice only in the hospital environment. This indicates that these mothers were not properly prepared with respect to breastfeeding during pregnancy. Adequate and consistent information and training even in primary service, during the prenatal care, on a regular and prolonged basis is considered fundamental for successful breastfeeding.¹⁹

During prenatal care, nurses contribute to the construction of an effective breastfeeding process. This process has as main attributions education, counseling, guidance, clarification and home monitoring, for bonding with the mother, patient safety, and adequate preparation to breastfeed before this practice starts.^1.8

Guidance and education are two of the main functions of nursing, whether at home or in the hospital.⁹ Research conducted in the countryside of Minas Gerais with mothers and nurses showed the difficulty of these professionals to carry out their role as educators because of their workload or lack of knowledge.^20-21

Despite the high number of mothers guided by nurses, 60.9% did not receive guidance from this professional category, confirming the gap in both levels, primary and tertiary health care. Most mothers who considered to have been guided indicated that the set of information received about breastfeeding was enough for the success of this practice. However, it is noteworthy that 29% of the mothers found them insufficient for their understanding. This revealed the need for attention and adequacy of this process in primary and hospital care.^22-23

An experimental study conducted in Fortaleza (CE) revealed that 100% of the mothers who received guidance on breastfeeding during hospitalization maintained exclusive breastfeeding for at least 60 days and showed greater self-efficacy in this process, while in the group that did not receive guidance only 41% maintained exclusive breastfeeding.^22-23 An integrative review highlighted the difficulty, incipience and inefficiency of the approach of nursing professionals regarding pregnant and puerperal women in relation to education on breastfeeding, leading to early weaning or gaps in this process.⁹

Most of the population reported having received guidance on breastfeeding during hospitalization, but it is important to highlight that 43.5% of the mothers were not instructed in the hospital environment about this practice after the birth of the baby. It is considered that the lack of information and training about breastfeeding promotes the search for feeding alternatives and hinders the adherence to exclusive breastfeeding. It is the responsibility of both health units and Family Health Strategy units, as well as professionals in the hospital environment, guide and educate mothers about breastfeeding.²²

Most of the women in this study said to feel confident to promote breastfeeding due to the support of the guidelines received at the hospital, indicating the importance of two primary points for the quality of this care: first, the articulation between primary and secondary health services during the follow-up of pregnant and puerperal women; and, second, the continuity of education on breastfeeding also in the hospital environment.^1,16 There is a need for prenatal and postnatal follow-up of nursing mothers, and it is generally still in the hospital environment that breastfeeding begins and the first doubts come up. This stresses the need for nurses to be professionally and technically prepared to provide this help.¹⁴

Regarding the knowledge of the mothers about the practice of breastfeeding, most knew that breastfeeding should be started in the first hour of life of the newborn, so as to reduce neonatal mortality and assist in the promotion, protection and support of breastfeeding.^18,24

An important gap was identified in the knowledge about the positioning of the baby to promote breastfeeding. When mothers adopt the correct position, they increase the chances of the baby being able to feed and decrease the chances of injury in the mother’s breasts, which predisposes to early weaning.^2,11 During the correct breastfeeding technique, which is the “correct latch”, the baby should have the mouth wide open, snapping up not only the nipple but also part of the areola; the tongue raises its lateral edges and the tip; the chin should touch the mother's breast, forming a shell; the lower lip should be facing outwards. This set of techniques enables the baby to breastfeed efficiently.¹

Gaps were identified regarding the knowledge of the correct breastfeeding of the baby among mothers, because they believed that the baby's chin should not touch the breast and that the baby's lower part should not be turned outwards. The correct position is as follows: the baby's belly facing the mother's body; the baby should be aligned with the head and spine straight on the same axis; the baby's mouth should be facing the nipple of the breast; the mother should hold the baby's body and butt with the arm and hand; the mother should place most of the areola (darker, rounder area of the breast) into the baby’s mouth; the baby's chin should touch the mother's breast; and the mother should not feel pain.¹

It is noteworthy that 46.4% of mothers reported that they could have weak milk. According to the literature, this is one of the main reasons why most mothers do not maintain exclusive breastfeeding, and also demonstrates the importance of nurses monitoring the practice of breastfeeding.¹Breast milk is not weak; on the contrary, it has all the necessary nutrients for the newborn according to its age and needs.^1,16

The mothers participating in the present study said that the correct time to breastfeed the baby should be indicated according to the behavior of the baby; it should stop when the bay does not want it anymore, ie "free demand". In contrast, a qualitative study conducted in a hospital in the countryside of Minas Gerais indicated that mothers and professionals defined a time for breastfeeding.²¹ The time during each feeding should not be fixed. Factors such as child hunger, interval since last breastfeeding and volume of breast milk stored may influence breastfeeding time. Most importantly, the mother must allow enough time to empty the breast.¹ The emptying of the breasts is also important for the baby's weight gain, because the baby receives the high-calorie milk at the end of the breastfeeding, promoting the newborn's weight gain.¹

Most mothers of the study mentioned that the same breast should not be offered in consecutive breastfeeding times, and about this aspect, it is noteworthy that the child should breastfeed until the emptying of the breast, because the milk at the end of the breastfeeding has higher fat content, bringing the feeling of satiety to the baby.^18,24

The population reported having knowledge about the definition of exclusive breastfeeding, but when asked about the time to continue exclusive breastfeeding, most of the participants did not know the answer. Exclusive breastfeeding is important for children up to six months of age because of its protective effects. A qualitative research conducted in a rooming-in unit in Rio Grande do Sul showed that the mothers recognized the importance of breastfeeding for the baby or the mother, but also confused the correct age of exclusive breastfeeding, likewise in the present research.²⁵

A limitation of the study was the low number of primiparous mothers admitted during the data collection period. In this context, we suggest further research addressing the necessary guidelines for the practice of breastfeeding and the way this process should occur, from primary to tertiary level of health care.

Final considerations

This study revealed that most of the mothers were instructed in the hospital environment and felt confident and satisfied with the information received from nurses, but there was a considerable number of mothers who pointed out the lack of guidance about breastfeeding during their pregnancy, and this has direct implications for the health of the mother-child binomial.

The mothers' knowledge of breastfeeding indicated important gaps as to the optimal position at the moment of breastfeeding, correct latch onto the breast, the existence of myths such as the belief that the milk offered by the mother during breastfeeding is weak, and the correct timing for exclusive breastfeeding. These gaps indicate the need to articulate the primary and tertiary levels of health care during the mother's follow-up in relation to the process of provision of guidance on breastfeeding, strengthening the embracement of this practice by the mother during the prenatal period and extending this educational process to hospital environment.

Final considerations

In most cases, nurses are responsible for the guidelines on breastfeeding, which indicates the importance of assuming their competences and educational skills, becoming one of their main approaches.

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Corresponding author

Nome: Thuanne Cristina Sousa E Aleixo

E-mail: thuannealeixo@hotmail.com

Endereço: Rua Engenheiro Djalma Sousa Borges, n° 638, Uberaba, Minas Gerais, Brasil

CEP: 38038-394

Author Contributions

1 – Thuanne Cristina Sousa E Aleixo

Planning of the research project, data collection, analysis and interpretation, writing and critical review.

2 – Ellen Carla Carleto

Planning of the research project, data collection and writing.

3 – Fabiana Cristina Pires

Planning of the research project, data collection and writing.

3 – Juliana da Silva Garcia Nascimento

Planning of the research project, data analysis and interpretation, writing and critical review.

How to cite this article

Aleixo TCS, Carleto EC, Pires FC, Nascimento JSG. Knowledge and analysis of the process of guidance on breastfeeding to mothers. Rev. Enferm. UFSM. 2019 [Acesso em: Anos Mês Dia];vol.9 e59: P1-19. DOI:https://doi.org/10.5902/2179769236423