Rev. Enferm. UFSM, v.12, e36, p.1-21, 2022

https://doi.org/10.5902/2179769268253

ISSN 2179-7692

Submission: 10/25/2021 • Acceptance: 3/18/2022 • Publication: 8/09/2022

Introduction. 1

Method. 1

Results. 1

Discussion. 1

Conclusion. 1

Refererences. 1

Review article

Weaknesses and potentialities of nursing care on breastfeeding in primary care: integrative review

Fragilidades e potencialidades do cuidado de enfermagem em aleitamento materno na atenção primária: revisão integrativa

Debilidades y potencialidades de la atención de enfermería en la lactancia materna en la atención primaria: revisión integradora

Gisele Basso Zanlorenzi^I

Marilene Loewen Wall^I

Juliane Dias Aldrighi^I

Deisi Cristine Forlin Benedet^I

Suellen Vienscoski Skupien^I

Silvana Regina Rossi Kissula Souza^I

^I Federal University of Paraná. Curitiba, Paraná, Brazil

Abstract

Objective: to identify the weaknesses and strengths of nursing care in supporting breastfeeding in Primary Health Care (PHC). Method: integrative review carried out in LILACS, BDENF, PubMed, EMBASE, CINAHL, Scopus, Web of Science and Scielo library in March 2021. Results: the sample comprised 19 studies. Weaknesses involve the nursing professionals' incipient theoretical/practical foundation, limited care focused on breastfeeding and the (dis)organization of the service and the work process. As a potential, health education was identified, developed by nurses, during prenatal and postpartum periods. Conclusion: the incipient theoretical/practical basis is responsible for the limitation of care, and the disorganization of the service and the work process is considered an obstacle in the support of breastfeeding in Primary Health Care. Health education actions prove to be a power and a possibility of offering quality care in the face of barriers imposed by lack of knowledge.

Descriptors: Maternal and Child Health; Nursing Care; Breast Feeding; Primary Health Care; Health Promotion

Resumo

Objetivo: identificar as fragilidades e potencialidades do cuidado de enfermagem no apoio ao aleitamento materno na atenção primária à saúde (APS). Método: revisão integrativa realizada nas bases LILACS, BDENF, PubMed, EMBASE, CINAHL, Scopus, Web of Science e biblioteca Scielo em março de 2021. Resultados: compuseram a amostra 19 estudos. Fragilidades envolvem embasamento teórico/prático incipiente dos profissionais de enfermagem, cuidado limitado voltado ao aleitamento materno e à (des)organização do serviço e do processo de trabalho. Como potencialidade, identificou-se a educação em saúde, desenvolvida pelo enfermeiro, durante o pré-natal e pós-parto. Conclusão: o embasamento teórico/prático incipiente é responsável pela limitação do cuidado, e a desorganização do serviço e do processo de trabalho é considerada um entrave no apoio ao aleitamento materno na APS. Ações de educação em saúde demonstram ser uma potência e uma possibilidade de oferta de cuidado de qualidade diante das barreiras impostas pela falta de conhecimento.

Descritores: Saúde Materno-Infantil; Cuidados de Enfermagem; Aleitamento Materno; Atenção Primária à Saúde; Promoção da Saúde

Resumen

Objetivo: identificar las debilidades y potencialidades de la atención de enfermería en el apoyo a la lactancia materna en la atención primaria de salud (APS). Método: revisión integradora realizada en LILACS, BDENF, PubMed, EMBASE, CINAHL, Scopus, Web of Science y biblioteca Scielo en marzo de 2021. Resultados: La muestra estuvo compuesta por 19 estudios. Las debilidades implican una base teórica/práctica incipiente de los profesionales de enfermería, cuidados limitados centrados en la lactancia materna y la (des)organización del servicio y del proceso de trabajo. Como potencialidad, se identificó la educación para la salud, desarrollada por enfermeras, durante el prenatal y el posparto. Conclusión: la incipiente base teórico-práctica es responsable de la limitación de los cuidados, y la desorganización del servicio y del proceso de trabajo se considera un obstáculo en el apoyo a la lactancia materna en la APS. Las acciones de educación para la salud demuestran ser un poder y una posibilidad de ofrecer una atención de calidad frente a las barreras impuestas por la falta de conocimiento.

Descriptores: Salud Materno-Infantil; Atención de Enfermería; Lactancia Materna; Atención Primaria de Salud; Promoción de la Salud

Introduction

In recent decades, Brazil has made progress in reducing infant mortality rates, partly as a result of the creation of the Unified Health System (SUS), which enabled prevention, promotion and basic care policies.¹ Despite progress, these rates are still unsatisfactory when compared to rates in developed countries, as there are regional disparities, with 9.2 deaths per thousand live births in the state of Espírito Santo in 2015, and 23.5 deaths per thousand live births in the same period in the state of Amapá.²

At the national level, infant mortality is mainly related to prematurity, diarrhea, congenital anomalies, birth asphyxia, neonatal sepsis and malnutrition, and mostly occur in the first month of the newborn's life. The absence of exclusive breastfeeding (EB) for up to six months, early introduction of food and lack of breastfeeding support actions in health facilities are factors that contribute to this outcome, as breast milk has a protective effect on infant morbidity and mortality.²

The increase in breastfeeding rates could prevent 823,000 deaths of children under five years of age each year in the world, as it is associated to the prevention of respiratory infections and episodes of diarrhea, and a 57% and 72% reduction in hospitalizations for the same causes, respectively.³

In this context, EB, up to six months of age, contributes to their healthy development, being relevant to achieving the Sustainable Development Goals (SDG) proposed by the United Nations by the year 2030, namely: health and well-being, zero hunger, quality education, poverty eradication, decent work and economic growth and reduction of inequalities.⁴

The relationship between breastfeeding and the SDG is due to its benefits in preventing maternal and child diseases, reducing malnutrition, better child neurodevelopment, which contributes to greater intelligence, resulting in better jobs in adult life, in addition to breast milk be available to children regardless of social class, which contributes to reducing social inequalities in low-, middle- or high-income countries.^3-6

In Brazil, the prevalence of EB in children under six months of age, in 1986, was 2.9%, however, according to results presented in national surveys and in Brazilian capitals carried out in 1996, 2006 and 2008, there was an increase. This rate reached 23.9%, 37.1% and 41%, respectively.⁷ However, in 2013, a decline in this frequency was identified, with 36.6%, as well as in relation to breastfeeding in children younger than 24 months, which showed a deceleration with a prevalence of 56.3% in 2006 and 52.1% in 2013.⁸

Preliminary data on breastfeeding indicators, made available by the National Study of Child Food and Nutrition, in which 14,584 Brazilian children under five years of age from February 2019 to March 2020 participated, demonstrate a new increase in these rates, with the prevalence of EB in children under six months of 45.7%, and breastfeeding in children under 24 months of 60.9%.⁹

Although the benefits of breast milk are consolidated, EB rates are still below the recommended by the World Health Organization, which recommends as one of the Global Nutrition Goals for the year 2025 to increase them to 50% worldwide.¹⁰

Therefore, it is understood that to achieve this goal, legal and social measures that promote comprehensive care for women's health are necessary,¹¹ with PHC being the main strategy for achieving the SDG¹ and the Global Nutrition Goals.

In addition to PHC being the gateway to health services in Brazil,¹² it is considered a privileged space for actions to promote, protect and support breastfeeding,¹³ and nurses can be strategic professionals, since they work with the dyad mother-baby at different moments of the puerperal pregnancy cycle.

However, there is evidence that despite women undergoing prenatal care at PHC, in certain regions of the country, they breastfeed without ever having received guidance.¹⁴ A study indicates that 40.6% of puerperal women did not receive guidance on breastfeeding during pregnancy, and of those who received it, 32% were guided by a nurse and only 11.5% took place in PHC.¹⁵ In this sense, the challenge is to develop new policies and strategies in the face of the current care model, in search of promotion, protection and support for breastfeeding, generating an increase in its rates.¹⁶

Research shows that individualized, continuous and regular education during prenatal care and postpartum support are related to increased EB rates, which can change the outcome of breastfeeding.¹⁷ The study corroborates the systematic review,¹⁸ which demonstrated the counseling as an effective public health intervention to increase breastfeeding rates, being most effective when performed prenatally and postpartum, either through home visits or continuous and regular telephone contact.

It is necessary to expand the access of population to comprehensive care with the intensification of actions to promote, protect and support breastfeeding. In this aspect, nurses play an important educational role, as they work throughout the pregnancy-puerperal cycle and relate to the population in all actions developed in PHC. Often, the nurse is the only source of information offered to women about the importance of breastfeeding, ¹⁹ being under her and the PHC's responsibility to guide and educate for breastfeeding.¹⁵

To support the development of policies and strategies in this context, the objective is to identify the weaknesses and potential of nursing care in supporting breastfeeding in PHC.

Method

The integrative literature review aims at investigating, analyzing and synthesizing knowledge on a specific topic using methodological rigor for the analysis of selected primary research.²⁰ For the development of the review, six steps were followed,²⁰ starting with the elaboration of the question using the acronym PICo,²¹ (P= population – nursing staff; I= interest – weaknesses, strengths and breastfeeding, Co= context – primary care to health), obtaining as a review: What are weaknesses and strengths of nursing care in supporting breastfeeding in PHC?

In compliance with the second stage, a search was carried out by a researcher in March 2021, in the health and multidisciplinary databases: Latin American and Caribbean Literature on Health Sciences (LILACS), Brazilian Nursing Database (BDENF) , Medical Literature Analysis and Retrieval System Online (MEDLINE)/United States National Library of Medicine (PubMed), Excerpta Medica Database (Embase), Cumulative Index to Nursing and Allied Health Literature (CINAHL), SciVerse Scopus, Web of Science and Scientific Library Electronic Library Online (Scielo), with CAFE access through the Portal of Periodicals of the Coordination for the Improvement of Higher Education Personnel (CAPES).

From this, search strategies were formulated according to each database, which were reviewed by two independent librarians from the Libraries of the Federal University of Paraná and Rio de Janeiro, as both are authors of guiding materials for searches in data base. The PUBMED strategy was: nursing OR nursings AND "breast feeding" OR "breastfed" OR "breastfeeding" OR "breast fed" OR "milk sharing" OR "sharing, milk" OR "breast feeding, exclusive" OR "exclusive breast feeding" OR "breastfeeding, exclusive" OR "exclusive breastfeeding" OR "wet nursing" AND "primary health care" OR "care, primary health" OR "health care, primary" OR "primary healthcare" OR "healthcare, primary" OR "primary care" OR "care, primary"

To define the sample, eligibility criteria were defined, and inclusion criteria were: publications available online in full, published in Portuguese, English or Spanish, in the years 2016 to 2021 and that addressed the object of study. The time frame was defined considering the holding in 2015 of the II Forum on International Cooperation in Human Milk Banks with the participation of 22 countries, in which guidelines for changes for the future were built, and the publication of the National Policy for Integral Attention to Child Health within the scope of SUS, which aims at promoting and protecting children's health and breastfeeding through care, comprehensive and integrated care from pregnancy to nine years of age.

As exclusion criteria, the following were considered: review studies, editorials, opinions, comments, monographs, dissertations and theses, or those whose theme did not meet the review question. EndNote Web Basic software (Clarivate Analytics®) was used to identify duplications resulting from research in various data sources, as shown in Figure 1.

Figure 1 – Flowchart of the selection of publications for the integrative review. Curitiba, PR, Brazil, 2021.

The selection of articles was performed by a researcher, after searching and analyzing the eligibility criteria. The third stage of the study consists of representing the characteristics of primary research. For this, information to be extracted from the selected researches was defined through the development of an instrument, which included country/year of publication/reference, objective, design/level of evidence, participants and main results.

The fourth stage consisted of analyzing the results, using seven levels for the classification of articles,²¹ these being: Level I – systematic reviews/meta-analysis of randomized clinical trials; Level II – randomized controlled clinical trials; Level III – non-randomized clinical trials; Level IV – cohort and case-control studies; Level V – systematic review of qualitative or descriptive studies; Level VI – single qualitative or descriptive studies; Level VII – expert opinion or consensus, none of which was classified as Level I, V and VII, because reviews and opinion studies are part of the exclusion criteria. Furthermore, at this stage, the information extracted from the articles was arranged in two pre-established categories, weaknesses and strengths, and grouped by similarity into four subcategories. The fifth stage was characterized by the discussion and interpretation of the results obtained, and the sixth stage consisted of the presentation of the evidence found.

Results

The final sample consisted of 19 scientific articles, resulting from the following LILACS distribution (n=9); BDENF (n=1); MEDLINE (n=5); Embase (n=1); CINAHL (n=2) and Web of Science (n=1). Regarding to the country of publication, 10 are national and nine are international, represented by the United States (2), Mexico (2), South Africa (2), Iraq (1), Ireland (1) and Turkey (1), with 10 published in Portuguese, eight in English and one in Spanish. There was a predominance of publications in 2020 (7), followed by 2019 (4), 2018 (4), 2017 (3) and 2021 (1). As for the Level of Evidence, 16 studies of Level VI, two of Level IV and one of Level II prevailed (Table 1).

Table 1 – Studies included in the integrative review. Curitiba, PR, Brazil, 2021.

Country/ year	Objectives	Method/ LE	Participants	Main results
Brazil, 2017^22	To know the difficulties to the establishment of Breastfeeding in the perspective of nurses from the Basic Health Care Network in the city of Rio Grande – RS.	Qualitative Level VI	47 nurses	Information obtained during graduation is insufficient, and training during professional life is scarce or non-existent. Faced to the lack of adequate support information and the insecurity pointed out by the nurses, they are in an unfavorable position to guide and interact with the community.
The United States of America, 2018^23	To identify the barriers of pediatric nurses in supporting maternal and infant breastfeeding.	Quantitative and Qualitative Level VI	33 pediatric nurses	Only 20% of nurses feel extremely prepared with knowledge acquired in postgraduate studies and 20% do not feel prepared. They report limited time to address problems related to breastfeeding and provide guidance, and little availability for classes or support groups for mothers.
Brazil, 2018^24	To describe the actions of nurses from the Family Health Strategy about the First Comprehensive Health Week in newborn care.	Exploratory descriptive, qualitative Level VI	9 nurses	Professionals fail to comply with the recommended time for home visits. The complete physical examination was not mentioned in the speeches, as well as guidelines were superficial, incomplete and some out of date. Identified lack of health education actions for these professionals.
South Africa, 2019^25	To investigate the knowledge and practices of primary health care nursing professionals in relation to HIV and the guidelines for infant and child feeding as revised by the 2013 policy.	Quantitative, transversal, descriptive Level VI	103 nursing professionals	Only 32% of nursing professionals received training on new guidelines, which resulted in low adherence to the new recommendations and inadequate information provided to the population.
Brazil, 2020^26	To describe how nurses from the Family Health Strategy work in the face of cross-breastfeeding, correlating it with the current issue of precarious work.	Descriptive, qualitative Level VI	6 nurses	Nurses presented autocratic speech, lack of dialogue and blaming the nursing mother for damage to the child's health. In the service, there is a shortage of training for professionals with institutionalized norms and routines, a large number of services for a short time, a pre-established goal, excess work and a shortage of professionals.
The United States of America, 2020^27	To assess attitudes towards breastfeeding and self-confidence in providing breastfeeding support by nurses who participated in the Ambulatory Program in Defense of Breastfeeding training.	Transversal Level VI	15 nurses	Lack of time and skills of health professionals can lead to missed opportunities to provide adequate support for breastfeeding. After completing the breastfeeding training program, nurses increased their attitudes and self-confidence in teaching and managing breastfeeding-related issues.
Mexico, 2020^28	To provide a detailed description of basic breastfeeding knowledge and skills among primary care physicians, nurses and nursing technicians working in units serving the population belonging to the PROSPRERA program, and assess the influence of semi-virtual training on knowledge and skills in breast-feeding.	Transversal Level IV	529 pre-training and 211 post-training professionals, including doctors, nurses and nursing technicians	Knowledge and skills about breastfeeding among nurses and nursing technicians working in Primary Care were relatively low before training. Conducting a semi-virtual training significantly improved the professionals' knowledge. However, skills-related improvements were achieved only for nurses.
Brazil, 2021^29	To analyze the association between the adequacy of the guidelines received during prenatal care and the professional who attended the pregnant woman in most consultations.	Transversal Level VI	3,111 postpartum women	Postpartum women attended only by the nurse received less guidance on the management of breastfeeding and 60% received guidance on exclusive breastfeeding up to six months. There is a biological approach to prenatal care and gaps in the guidelines offered by professionals.
Brazil, 2020^30	To identify the nursing care behavior in the face of cross-breastfeeding.	Qualitative, descriptive Level VI	6 nurses	The use of censorship, prohibitive/prescriptive method in nursing consultations and lack of dialogue were evidenced.
Brazil, 2018^31	To verify the actions developed by nursing professionals in the care of pregnant women in Primary Health Care Units in a municipality in the south of Minas Gerais.	Transversal, descriptive, Level VI	5 nurses and 4 nursing technicians	Breast examination was rarely performed during prenatal care and guidelines on breastfeeding were insufficient. Units formed a group of pregnant women, and the nurse was willing to give lectures/workshops on health education. Administrative-management and assistance activities generate work overload. The lack of systematization reflects on care.
Brazil, 2017^32	To understand the interference of popular practices and beliefs in early weaning in postpartum women assisted in the Family Health Strategy.	Descriptive, qualitative Level VI	12 puerperal women	Most puerperal women did not receive guidance on breastfeeding during prenatal care. Those who received it mentioned the nurse as a professional who provided guidance, but they were somehow deficient.
Brazil, 2019^33	To describe the difficulties and strategies used by women to maintain breastfeeding after returning to work.	Descriptive qualitative Level VI	20 women	Only 3 participants reported the figure of the nurse as the main source of guidance in adapting to returning from work.
Mexico, 2018^34	To analyze the knowledge and practice on breastfeeding of primiparous women who are entitled to care at the Family Health Unit n. 80 of the Mexican Institute of Social Security in the city of Morelia, Michoacán.	Transversal, descriptive Level VI	75 primiparous	Regarding to knowledge about how to breastfeed your baby, 61.3% of the participants reported knowing how to do it, and 54% of them reported that they learned from a professional nurse. However, when demonstrating the technique, 48% demonstrated the correct form.
South Africa, 2019^35	To determine the attitudes of nursing professionals in relation to the implementation of the Mother and Baby Friend Initiative in Primary Health Care in the town of Makhuduthamaga in the Limpopo province.	Descriptive, quantitative Level VI	153 nursing professionals	Professionals showed negative attitudes, considering that the initiative takes more time and represents an overload for the team. Most nursing assistants did not teach women about the benefits of exclusive breastfeeding, disagreed about its exclusivity until six months and did not protect, support and promote breastfeeding. Technicians and nursing assistants agreed that breastfeeding is for poor people, that babies before six months should receive mixed feeding and working mothers cannot breastfeed.
Brazil, 2019^36	To know the clinical and epidemiological profile of child health during the first year of life.	Transversal Level VI	61 medical records	No visits were made in the first week of life. The bond between nurse and user was the main factor for mothers to return to the service. There was no record of exclusive breastfeeding in the medical records.
Iraq, 2020^37	To assess the effectiveness of nursing intervention on breastfeeding self-efficacy, knowledge and attitude of a sample of women in Iraqi Kurdistan.	Experimental Level IV	130 pregnant women	The self-efficacy of breastfeeding and exclusive breastfeeding can be increased with nursing actions performed in prenatal care.
Brazil, 2020^38	To analyze the contribution of nurses to breastfeeding in primary care.	Exploratory, descriptive, qualitative Level VI	20 users	Guidance provided in prenatal consultations contributed to women's adherence to breastfeeding. The puerperal visit provided greater security and comfort, with the clarification of doubts and anxieties.
Ireland, 2017^39	To investigate the experiences of women who attended a breastfeeding group led by a public health nurse in a formula-feeding culture.	Descriptive, qualitative Level VI	7 women	Women considered the nurse's participation positive for transmitting scientific knowledge, offering practical support in relation to latching and having the possibility of evaluating the baby's weight gain.
Tukey, 2020^40	To assess the effect of an internet-based program for primiparous women on infant growth and development, infant health, and level of maternal self-efficacy.	Randomized controlled trial Level II	71 women	After using the program by nurses, the rate of exclusive breastfeeding was higher in the intervention group, and there was a reduction in other foods offered to babies in the same group. Nurses can more easily, quickly and systematically conduct education, consultation and follow-up for health promotion and protection through internet-based programs.

LE = level of evidence

From the reading to the articles, the themes that emerged were organized into subcategories grouped into two main categories: “Weaknesses of nursing care in supporting breastfeeding in Primary Health Care” and “Potentialities of nursing care in supporting breastfeeding in Primary Health Care”.

Weaknesses of nursing care in supporting breastfeeding in Primary Health Care

The approach on weaknesses was predominant in publications related to the incipient theoretical/practical basis of nursing professionals on breastfeeding care in PHC; the limited care focused on breastfeeding in PHC and the (dis)organization of the service and the work process as obstacles to nursing care in supporting breastfeeding in PHC.

Incipient theoretical/practical basis of nursing professionals on breastfeeding care in Primary Health Care

Studies have indicated insufficient preparation on breastfeeding at undergraduate and graduate levels,^22-23 lack of health education actions,²⁴ training,²⁵ and qualifications during the trajectory of these professionals in health services,^22,26 and insecurity and lack of ability of nursing professionals for decision-making related to breastfeeding.^22,27-28 Knowledge gaps were demonstrated as a result of weaknesses in the theoretical/practical basis of nursing professionals.²⁹

Limited care focused on breastfeeding in Primary Health Care

In this subcategory, weaknesses were associated with the biological view,²⁹ the use of autocratic speech, of blame, with lack of dialogue,²⁶ use of censorship, prohibition and prescriptive posture of nursing professionals towards mothers.³⁰ As well as the insufficiency in the provision of guidelines on breastfeeding,^24,29,31-34 passing on inadequate,^22,25,35 or outdated information to health service users,²⁴ deficiency in performing the physical examination of the puerperal woman and the clinical examination of the breasts in pre-natal consultations natal care,^24,31 lack of registration of information about EB in the medical records of the users,³⁶ and the failure to carry out home visits in the first week of the baby's life.^24,36

Mid-level nursing professionals were mentioned in two studies,^28,35 which point out that they did not protect, support or promote breastfeeding,³⁵ and that carrying out a semi-virtual training did not improve the skills of nursing technicians, suggesting the intensification of practical training.²⁸

The (dis)organization of the service and the work process as obstacles to nursing care in supporting breastfeeding in Primary Health Care

Work overload with administrative-management and care activities,^26,31,35 lack of nursing professionals,²⁶ institutionalized norms and routines with pre-defined goals,²⁶ short period of time to provide care,^{23,26-27, 35} and lack of systematization of the work process,³¹ point to weaknesses that influence nursing care in breastfeeding.

Potential of nursing care in supporting breastfeeding in Primary Health Care

Potentialities of nursing care in supporting breastfeeding refer only to nurses, as the studies did not address nursing assistants and technicians in this aspect. With discrete representation among the articles, the potential refers to health education developed by nurses during prenatal and immediate postpartum.

Health education developed by nurses during prenatal and immediate postpartum

Nurses' potential is linked to the development of groups of pregnant women, lectures and workshops during prenatal care, which promote health education and increase the mothers' self-efficacy of breastfeeding,^31,37 carrying out prenatal consultations with the transfer of guidelines on breastfeeding, as well as the puerperal visit that promotes safety, comfort, clarification of doubts and anxieties.³⁸

Breastfeeding support groups are also seen as potentialities, as they enable nurses to share scientific information, offer practical support in relation to latching and assess the baby's weight gain,³⁹ in addition to the bond established between professional and user, which is directly related to mothers' adherence to the health service.³⁶ A study,³⁴ showed that 54% of mothers who reported having knowledge about how to breastfeed their baby learned from the nurse.

The use of an internet-based education program during prenatal care and follow-up after childbirth are also potentialities, as in addition to contributing to the education, guidance and monitoring of pregnant and lactating women in an easier, faster and more systematic way, they are associated with a higher rate of EB.⁴⁰

Discussion

For nursing professionals to have a theoretical/practical basis and to offer quality care, with a view to achieving success in actions aimed at breastfeeding, solid training is needed, which correlates theory and practice.⁴¹ However, a study shows that, in the In Brazil, the preparation offered during graduation is often insufficient.²² In view of this, other opportunities for acquiring knowledge should be encouraged to undergraduate students, such as participation in optional courses, extension projects and events.⁴²

The insufficiency of university education leads nurses to seek security in the postgraduate course to carry out their activities and expand their knowledge. However, in order to achieve these goals, they need to commit and be able to build their training, becoming co-responsible and subjects of their learning.⁴³

Results show^27-28 that in the United States and Mexico, the development of health education actions, training and qualifications in the work environment have an important association to improvements in the knowledge and skills of health professionals, being a great opportunity to correlate theory and practice. In this way, weaknesses resulting from the training process can be addressed by carrying out in-service educational activities, minimizing the impact generated in nursing care.

In contrast to the technical and imposing approach evidenced in studies carried out in Brazil,^26,29-30 the use of bonding and embracement as care technologies are related to higher rates of breastfeeding,⁴⁴ as they facilitate the learning process by stimulating autonomy and considering the user as a central figure, in addition to promoting co-responsibility in the adopted behaviors and dialogue with active listening, valuing the exchange of experiences between users and professionals in a simple and empathic way.^19,44

Regarding to the insufficiency of guidelines provided in PHC, evidenced both in Brazil and in Mexico,^24,29,31-34 a study carried out with 69 postpartum women in a teaching hospital located in the interior of the state of Minas Gerais showed that 59.4 % of nursing mothers received guidance on breastfeeding during pregnancy, 32% of which were provided by a nurse, and only 11.5% of the total guidance occurred in the PHC.¹⁵

In addition to the lack of information, inadequate transfer by Brazilian and South African professionals^22,25,35 and the exposure of Brazilian women to outdated behaviors²⁴ are factors that can lead to early weaning.⁴⁵

Despite the existence of a specific program on breastfeeding in PHC, Strategy Breastfeeds and Feeds Brazil, in the multidisciplinary team there is often no professional who is responsible for providing guidance on this topic to women during prenatal care and is a reference for effective follow-up after childbirth. The practice of offering shared guidance helps PHC professionals believe that other team members will provide guidance on breastfeeding at an opportune time, which may or may not result in the prioritization of this topic during consultations.⁴⁶

The performance of nurses in accordance with the ethical and legal precepts of the profession also presented weaknesses, because despite the physical examination being considered an activity inherent to professional practice,⁴⁷ in Brazil it has been increasingly neglected,^24,31 as well as the record of the information obtained.³⁶ In this sense, the Nursing Process is considered a working method, as it clarifies care and documents professional practice through five interrelated, interdependent and recurrent steps, however, there is a limitation regarding its use in a systematic way.

Mid-level nursing professionals were mentioned in two studies carried out in Mexico and South Africa,^28,35 with important weaknesses in their care being evidenced. It is considered a paradox in Brazil that the National Primary Care Policy¹² contemplates the nursing assistant or technician as professionals who should minimally compose the family health team, and the performance of these professionals does not emerge in a representative way in the Brazilian studies selected in this review. This fact highlights the importance of nurses rescuing shared educational activities together with their team, making their supervisory role effective for these professionals, in order to identify knowledge gaps and reorganize work processes that are not in line with the best available scientific evidence.

The (dis)organization of the service and the work process were identified as obstacles to nursing care in supporting breastfeeding in PHC. Research points to the discontinuity of health care professionals focused on breastfeeding related to gaps in the structure of health services, among them the lack of time for care provided during prenatal care.⁴⁶

Corroborating this, the context of PHC is conducive for nurses to expand their role and work with the population, increasing their scope of work and being resolute in the face of the demands presented, as the clinical performance of nurses favors the integrality of care and expands access to health by the population. However, to consolidate clinical practice, nurses need to reorganize their work process, so as to overlap actions focused on supervision activities and service organization, remaining closer to the individual, family and community.⁴⁸

The decentralization of care and its consequent fragmentation, generates precariousness of nursing care, and results in weaknesses in the work process,⁴⁹ which affects not only the health of the worker, but also the functioning of health services, the quality of care and the user security. From this perspective, to strengthen the nursing work process and minimize obstacles to the know-how of the profession, the category needs to develop strategies for self-appreciation and rescue the essence of their work, such as presence, listening and care.⁵⁰

Related to the potential, the health education promoted by nurses during the prenatal and immediate postpartum period identified in Brazil and Turkey^31,38-40 corroborates the systematic review that points to the optimization of breastfeeding rates through the implementation of educational activities, as well as such as individualized and prolonged care for women, the offer of telephone support associated to conventional care, and the nursing mother's easy access to the health team.⁵¹

In the postpartum period, home visits are an extension of care and considered a protective factor for EB, as it brings health professionals closer to the family's reality, makes it possible to assess the relationship between mother and child, provide guidance, support and identify inadequate techniques breastfeeding, being considered a unique moment to clarify doubts. It should be performed within seven days after delivery, as it is a decisive period for the establishment and maintenance of breastfeeding, and because the mother is often insecure and emotionally fragile.^13,52

The use of educational technologies, such as information and communication technologies, is being widely disseminated in the health area and has been used in the dissemination of knowledge in the area of breastfeeding. Technological resources, such as internet-based programs, are a new way of transmitting information in the search for the subject's autonomy in solving problems. In this sense, the use of technologies, whether managerial, educational or care, is associated with higher rates of EB, with nurses having the role of mediator of health education actions, as they are inserted in different levels of care.⁴⁴

It is evident that although nurses are present at different levels of care, when it comes to breastfeeding, no health professional is in charge of the entire continuum of care.⁴⁶

The limitations of the study are the time frame and the language delimitation for the search for articles that can focus on the possibility of not exhausting all publications on this topic, in addition to the selection of articles carried out by a researcher, after the search and analysis of the eligibility criteria. Furthermore, the delimitation of the search strategy for descriptors and keywords that do not mention all the categories that make up the nursing team may have resulted in studies focusing on the care provided only by nurses. Despite the limitations, the findings present relevant contributions and points that can be intervened in search of a change in this scenario.

The results contribute to the development of policies and strategies aimed at training and updating nursing professionals on the topic of breastfeeding, as well as the implementation of improvements in PHC services, since gaps in the care provided corroborate for less information about the theme and, consequently, interfere in the breastfeeding rates of the population assisted by them. The results also point to actions that should be strengthened, as they are considered by the studies as nurses' potential.

Conclusion

The incipient theoretical/practical basis of nursing professionals is responsible for limiting care focused on breastfeeding in PHC. In addition to aspects related to the training and improvement of nursing professionals that result in the weakening of care, the disorganization of services and the work process is considered an obstacle in the support of breastfeeding. However, health education actions developed by nurses during the prenatal period and in the immediate postpartum period prove to be a power in supporting breastfeeding and a possibility of offering quality care in the face of barriers imposed by lack of knowledge.

Therefore, considering the multi-professionality, it is important that there is an offer of qualifications and training in order to overcome the incipient theoretical/practical basis on the subject. Within the scope of the nursing team, in addition to the benefits described, qualifications and training can rescue the essential aspects of the profession, such as presence, listening and care, overcoming the limitations of care aimed at breastfeeding. In addition, there is a need for managers to engage with the teams, so that the services are organized and the work process is structured to achieve these improvements.

Health education actions carried out by nurses are a potential that must be reinforced, stimulated and developed by the entire team. Professionals should make use of technology in their care, offer guidelines consistent with the available scientific evidence, follow the ethical and legal precepts of each profession, carry out early home visits, offer individualized and prolonged care, narrow the access of population to the team, and, if possible, incorporate a nurse who is responsible for the continuity of care aimed at breastfeeding from prenatal to postpartum.

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Author contributions

1 – Gisele Basso Zanlorenzi

Corresponding author

Nurse, Specialist in Family Health Strategy. E-mail: giselezanlorenzi@gmail.com

Contributions: design, research development, manuscript writing, review and approval of the final version.

2 – Marilene Loewen Wall

Nurse, Doctor in Nursing. E-mail: wall@ufpr.br

Contributions: design, research development, manuscript writing, review and approval of the final version.

3 – Juliane Dias Aldrighi

Nurse, Master in Nursing. E-mail: juliane.aldrighi@gmail.com

Contributions: review and approval of the final version.

4 – Deisi Cristine Forlin Benedet

Nurse, Doctor in Nursing. E-mail: deisiforlin@yahoo.com.br

Contributions: review and approval of the final version.

5 – Suellen Viencoski Skupien

Nurse, Master in Health Technology. E-mail: suvienscoski@hotmail.com

Contributions: review and approval of the final version.

6 – Silvana Regina Rossi Kissula Souza

Nurse, Doctor in Nursing. E-mail: skissula@gmail.com

Contributions: review and approval of the final version.

Chief Scientific Editor: Cristiane Cardoso de Paula

Associate Editor: Aline Cammarano Ribeiro

How to cite this article

Zanlorenzi GB, Wall ML, Aldrighi JD, Benedet DCF, Skupien SV, Souza SRRK. Weaknesses and potentialities of nursing care on breastfeeding in primary care: integrative review. Rev. Enferm. UFSM. 2022 [Access in: Year Month Day]; vol.12 e36: 1-21. DOI: https://doi.org/10.5902/217976968253