Interfaces of the discontinuation of breastfeeding

Interfaces da descontinuidade do aleitamento materno

Breastfeeding (BF) is the isolated strategy on public health with the greatest potential for reducing child mortality, has a direct or indirect impact on the future life of the individual, helps reduce the risk of chronic diseases such as hypertension, diabetes and obesity, and reduces the risk of breastfeeding women developing cervical and breast cancer. It brings benefits to both infant and mother, treats the physical and mental health, and has a positive influence on the affective relationship between mother and child (Boccolini, Carvalho, Oliveira, & Vasconcelos, 2011; Brasil, 2011).

Despite the acknowledged benefits of breastfeeding and the significant advance in its practice, there is still a gap that separates current practices from the recommendations for BF. Although the World Health Organization (WHO, 2010) advocates Exclusive Breastfeeding (EBF) in the first six months of life, only five of the 19 Latin American countries carry out this practice with more than half of infants (Pan American Health Organization [PAHO], 2012).

Brazil has been making progress with breastfeeding. According to a research that assessed the prevalence of BF in the country (Venancio, Escuder, Saldiva, & Giugliani, 2010), the average duration of breastfeeding increased from 296 to 342 days, and from 23.4 to 54.1 days for exclusive breastfeeding (EBF), from 1999 to 2008. However, despite positive data, the progress reported by the research is far from ideal; this fact is influenced by several factors such as beliefs and cultural practices (Brasileiro, Posson, Carrascoza, Ambrosano, & Moraes, 2010).

A study involving women who had had at least one previous child, conducted in a maternity hospital in the city of São Paulo that promotes breastfeeding, identified mistaken BF practices. It is noteworthy that 30% of the sample reported the introduction of other liquids before six months of life. This suggests that the concept of BF is not well understood. Another interesting piece of data was the addition of other types of milk by 77.3% of unemployed women even though it is believed that they have time to breastfeed (Campos, Chaoul, Carmona, Higa, & Vale, 2015)

Early introduction of food to supplement breast milk is associated with higher incidence of anemia, hospitalizations for diarrheal diseases and pneumonia, and compromises the child’s growth. Among cultural habits, the use of pacifiers stands out as being harmful to breastfeeding because it reduces its frequency, which may lead to reduced milk production (Silva et al., 2009; Jaafar, Jahanfar, Angolkar, & Ho, 2012)

The strategy set by the Brazilian Health Ministry in 2011 within the context of the Brazilian Unified Health System (Sistema Único de Saúde) (SUS), the ‘Stork Network’, relies on maternal-infant care, contributes to an interdisciplinary action at different levels of health care and, above all, ensures mothers their right to prenatal care, and children their right to healthy growth and development through breastfeeding and follow-up from 0 to 24 months of age, period during which the WHO recommends breastfeeding (WHO, 2010; Brasil, 2011).

Knowledge passed on to mothers about EBF in order to educate them should prioritize factors that influence early weaning and its disadvantages, emphasizing how said factors can affect the health of mothers and children. The construction of this knowledge, when enabled in the prenatal period, increases the desire to breastfeed. Thus, at the first newborn’s medical visit this desire should be encouraged so as to improve the infant’s development and reduce child morbimortality.

Therefore, the factors that influence the discontinuation of EBF raise some questions: What knowledge do mothers have on the potential of breastfeeding for the health of their children? Do prenatal visits constitute field for the intervention of health professionals in educational strategies? What, in the daily routine of mothers, contributes to early weaning?

The relevance of BF to a child’s healthy growth and development brings the need to learn the prevalent factors that contribute to the addition of other foods during the period in which only breast milk would be enough, even with the existence of policies that support this practice. Thus, the study was conducted with the aim to identify the conditioners of the discontinuation of exclusive breastfeeding.

This is a qualitative study conducted in a Primary Health Care Unit (PHCU) of the Family Health Strategy (FHS) in Fortaleza, Ceará State, Brazil, that was chosen due to the volume of records of children within the territory covered by the VI Regional Executive Secretariat. A total of 20 mothers of children aged 0-6 months old participated. The data saturation principle was adopted contemplating those women who were currently breastfeeding. Inclusion criteria consisted of mothers aged between 19 and 30 years old who were not breastfeeding exclusively. The study excluded mothers of children with congenital malformations that could hinder breastfeeding, such as lip and palate cleft, and children with complications that required intensive care for any period.

Data was collected from October to November 2011, before or after well-child care visit. A questionnaire was applied in order to characterize the participants. Subsequently, semi-structured interviews were conducted, being composed by the following guiding questions: What do you understand by breastfeeding? What did lead you to early weaning? Did you receive any guidance on breastfeeding at prenatal visits? The interviews were recorded and transcribed, but in order to preserve anonymity the statements were coded by the letter M plus an Arabic number.

All the empirical material was subjected to an adaptation by content analysis in its thematic modality, which consists of unveiling cores of meaning that compose the communication, whose frequency of appearance may relate to the object analyzed. The next step was coding, through which themes were identified and later sorted into categories that were then subjected to an analysis subsidized by the literature (Bardin, 2011). The categories of analysis were constituted as follows: Guidance received during prenatal care; Meanings of breastfeeding; Determinants of early weaning.

In compliance with the guidelines and norms for research involving humans, based on Resolution No. 196/1996 of the National Health Council, the participants signed an informed consent form. The study was approved by the Research Ethics Committee of the University of Fortaleza (Universidade de Fortaleza) under legal opinion No. 389/2011.

The characterization of the interviewees evidenced average age of 23 years old- ranging from 19 to 30 years old, predominance of ongoing middle-level education, a majority of single women, and a slight difference between informal workers and housewives, the latter being the outstanding ones.

The mother’s young age and the absence of a stable union are favorable conditions for the interruption of breastfeeding (Bernardi, Jordão, & Barros Filho, 2009), and so is the few years of study (Nesbitt et al., 2012).

By unveiling the knowledge built about breastfeeding, it can be observed that it is not based on scientifically-founded information, but rather supported by past experiences with other children. Moreover, the poor performance of health professionals, particularly when it comes to instructions given during prenatal care, may play a significant role in the reduction of this practice.

VI did not receive any instructions on how to breastfeed my son; I only knew how to do it because of the experience I had with my other daughter. [...] (M11).

They did not give me any instructions at the prenatal visits; they did not say anything about breastfeeding. I got to learn about it just now during the well-baby check-up [...] (M18).

Instructions given during the gestational period are about the care of the breasts, benefits of breastfeeding to mother and baby, how to breastfeed and the importance of EBF on demand. This educational conduct and the participation in groups for expectant mothers directly influence the continuation of breastfeeding (Camarotti, Nakano, Pereira, Medeiros, & Monteiro, 2011; Leal, Fialho, Dias, Nascimento, & Arruda, 2011; Sassá et al., 2014).

The promotion of guidance soon during pregnancy has a positive impact on breastfeeding prevalence (Camarotti et al., 2011). The poor conduction or the absence of this educational practice prevents women from complying with breastfeeding, and children from benefiting from it; furthermore, one must consider the quality of information and the level of understanding of those involved.

The little knowledge of mothers about breastfeeding is made clear in the superficial information acquired regarding appropriate duration, with little emphasis on real benefits.

Yes, I did receive it… about the importance… that you can breastfeed until they are two years old or at least they are six months old (...) (M12).

[…] at the prenatal visit I was told we have to breastfeed until they are 6 months old, without giving them any other type of food, just breast milk […] (M2).

Yes, I did receive it… that breastfeeding was good because it would make the baby stronger […] (M4).

Education practices are devices that can boost EBF. The challenge is in learning the sociocultural context and the mother’s difficulties and facilities in order to identify behaviors that indicate the option for weaning and early introduction of supplementation in the newborn’s diet (Brasileiro et al., 2010).

Therefore, it is up to the professional to identify and understand the breastfeeding process in the sociocultural and family context and, from this understanding, care for both mother and baby and their family. The motivational intervention stems from a strategy adopted during prenatal care whose contribution is the possibility to change the learned behavior and reduce ambivalence in decision making in favor of a healthy breastfeeding practice (Bernardi et al., 2009).

Prenatal care is regarded as an opportune time to encourage women to breastfeed. However, a portion of the mothers reported not actively attending all visits, situation which impairs the educational work developed by the healthcare professional.

I did not receive it because I did not attend any prenatal visit […] (M13).

I did not receive it because I missed some prenatal visits […] (M17).

The relationship established between the professional and the pregnant woman during prenatal visits with the purpose of encouraging and promoting confidence avoids doubts, absences, difficulties and possible complications. It is the professionals’ duty to have knowledge of breastfeeding and skills, but above all they need competence to establish an effective dialogue because through it they help the mother with her choices, making her a subject capable of changing her own reality.

Breast milk is recognized as a potentially beneficial food for the baby, understood as a safe means to ensure good health. Such evidence corroborates with the Brazilian Ministry of Health, which highlights healthy growth as the effect of an adequate diet (Brasil, 2009). In the early stage of life, human milk contains ideal nutritional characteristics, proper balance of nutrients, in addition to developing immunological and psychological advantages, with effect on the reduction of infant morbimortality. The certainty that BF brings benefits to child development permeated the interviewees’ speeches.

[…] I think it is ideal for the baby; he grows and develops faster […] (M5).

I think it is important, essential to the child’s growth, right? Up to six months at least (M8).

I think mothers really have to breastfeed (M13). He grows so big […] (M19)

It can be seen that mothers, though not knowing the composition of breast milk, know that breastfeeding has a protective effect on the baby’s health. It is also noteworthy that the benefits of breastfeeding when it comes to the advantages related to children are better known by the mothers.

I think it is great! It prevents the child from getting the flu and other diseases […] (M3).

I think it is a good thing for him because it prevents infections and other things; it satiates the baby […] (M14).

I think this is the most important period for the baby because it is when he develops immunity […] (M20).

A study conducted with 230 postpartum women revealed that 91% of them knew of some advantage of BF, with disease prevention being the most mentioned benefit (Boccolini et al., 2011). Breast milk has biochemical characteristics that make it the only food capable of protecting the infant from some health risks in the first months of life, especially gastrointestinal and respiratory problems. Its richness in nutritional and immunological elements sets it apart from other milks and other foods which, besides lacking these protective components, may develop diseases in newborns (Passanha, Cervato-Mancuso, & Silva, 2010).

The bond between mother and child during breastfeeding was present in the speech of only one interviewee. This fact may result from poor guidance received during prenatal care, since the health education process stimulates reflections and facilitates the construction of knowledge.

[…] it is a way to pass love onto her and it is also good because breast milk has everything, you do not need medication, it has everything the child needs and prevents diseases […] (M15).

Breastfeeding is a natural bonding, affection, protection and nutrition strategy for the child (Boccolini et al., 2011). It is therefore able to allow for a favorable impact on the promotion of the mother’s and the child’s health. The participants showed an understanding of the potential of BF for babies. In their view, breast milk is linked to the child’s health, specifically to prevention of diseases and a healthy growth and development. However, the advantages of breastfeeding for mothers are not mentioned in their speeches, revealing a gap in their knowledge.

Through content analysis it was possible to identify the mothers’ interpretation of the baby’s crying as a motivating element for the introduction of other foods and early weaning. By inquiring them about the reasons that led to the interruption of breastfeeding, it was possible to notice a free association of crying with hunger and, thus, with the idea that the milk was weak and not enough to satiate the child.

The reports translate the mothers’ idea that their milk is ‘weak’. Their insecurity and anxiety can therefore impair breastfeeding. This data corroborates the qualitative study conducted by Frota et al. (2013) in the municipality of Maranguape (Ceará, Brazil), which brings in its results the belief that breast milk is weak and incapable of satiating the child as an excuse for mothers to introduce other types of milk.

[…] breast milk was not enough to my son […] he cried too much! (M3).

[…] she cried a lot, so I began to feed her another type of milk and then she began to sleep the whole night. I think it was hunger […] (M6).

[…] I did not have much milk and he cried a lot because he was hungry; I would try to pump but I could not, so I lost my patience and gave him porridge. He liked it so I kept doing that […] (M11).

[…] I would give her breast milk but she would not stop crying, as if it was not enough, so I began to give her porridge and she began to sleep the whole night […] (M12).

Weak milk is a social construction used as an excuse for weaning and early supplementation. It is evident that, although they know that breast milk has health benefits, these women know little about its production and volume (Rocci & Fernandes, 2014). Mothers should be made aware of the babies’ difficulties as to the adaptation to extrauterine life and the relationship of this experience with crying.

It is imperative that health professionals are prepared to listen to mothers, understand their complaints and mistrust in order to realize the difficulties presented and teach them about the production and volume of breast milk, as well as techniques for breast handling. Developing self- confidence is necessary for a successful BF; the positive points involving the mother’s successes should be acknowledge and praised.

The working conditions and education of these mothers were identified as factors that could influence early supplementation. In contrast, study results show that unemployed women were the ones that most offered another type of milk before six months of age (Campos et al., 2015). This contradiction may be associated not with the mother’s absence when going back to work or school, but rather with the knowledge of the actions that can be performed for maintaining EBF.

I had to go back to school; I could not stay there just breastfeeding […] (M9).

[…] I did not want it but I had to add other foods because of my financial situation […] I have to work […] (M13).

[…] I had to go back to work so I began to give him juice and baby food; that was sad […] (M14).

It was found that the continuation of breastfeeding after the return to work is influenced by the following factors: participation in programs that encourage breastfeeding; offering breast milk pumped into a glass; not adding infant formula into the bottle; and being able to breastfeed during working time (Brasileiro et al., 2010). Thus, it is understood that the mothers’ autonomy achieved by the exchange of knowledge with health professionals and the opportunity to breastfeed while at work or school favor the continuation of EBF.

In this context, low socioeconomic status also appears as a justification for early weaning and/or supplementation. However, breastfeeding plays an important role in a family’s budget and government spending. Costs with artificial foods are higher when compared to human milk; there are also indirect costs such as money spent on medication, hospitalizations and days away from work or school because of diseases that could be prevented by means of exclusive breastfeeding until the sixth month of life (Caminha, Serva, Arruda, & Batista Filho, 2010).

Protection against childhood diseases is conferred by the nutritional factor of breast milk; daily consumption of 500 mL is capable of providing approximately 75% of energy requirements, 50% of protein requirements and 95% of vitamin A requirements (Organização Mundial da Saúde, 2001).

Other difficulties like the baby’s and the mother’s inability as to the correct breastfeeding positioning were addressed by the interviewees as a reason for early weaning.

[…] he did not want my breast anymore, he could not grab it! (M1).

The health care professional assisting in prenatal care should be able to stimulate the desire to breastfeed and provide the necessary guidance on techniques that facilitate such practice. The plurality of situations that bring difficulties to BF can be overcome when the professional performs an effective follow-up (Leal et al., 2011; Brasil, 2011).

Nursing strike may be associated with the mother’s inexperience or lack of knowledge about the correct positioning for properly handling breastfeeding (Barennes et al., 2012). Educational strategies are capable of promoting and sustaining EBF. It is known that several factors such as use of bottles for drinking water, teas and juices, and use of pacifiers to soothe the crying baby may create longer intervals between feedings and lead to confusion between the mother’s nipple and the artificial nipples (Jaafar et al., 2012; Neu, Silva, Mezzomo, & Busanello-Stella, 2014).

Most nursing mothers are biologically able to breastfeed and have enough volume of milk to meet the needs of their babies. The study showed that the discontinuation of BF is triggered by various reasons, including education, work, the idea that breast milk is weak and small in volume, and lack of practical skill. These are factors recurrently pointed by the mothers for early weaning. Thus, family and professional support are of great importance to maintain breastfeeding until the sixth month of life.

The determinants of the discontinuation of EBF or early weaning within the group studied are: lack of understanding about the benefits of breast milk to the health of children and failure to recognize the benefits to the health of mothers themselves. This shows that knowledge is insufficient and inconsistent especially concerning the understanding of the production and volume of milk and factors related to the baby’s satiety. In this respect, it is revealed that cultural knowledge is passed on to generations, according to which there is a strong relationship between crying, hunger and the need for food supplementation.