RESEARCH ARTICLES

Ineffective breastfeeding among nursing mothers assisted at basic health units

Liana Jéssica Queiroz de Freitas^I; Nayana Casteliana Cavalcante Castelo Melo^II; Mayenne Myrcea Quintino Pereira Valente^III; Escolástica Rejane Ferreira Moura^IV; Camila Félix Américo^V; Carla Suellen Pires de Sousa^VI
INursing Student. University of Fortaleza. Ceara, Fortaleza, Brazil. Email: de_ca_lia@hotmail.com.
^IINursing Student. University of Fortaleza. Ceara, Fortaleza, Brazil. Email: nayanacavalcante@hotmail.com.
^IIINurse. Doctoral Student in Nursing from the Federal University of Ceara Assistant Professor an the University of Fortaleza. Ceara, Fortaleza, Brazil. Email: mayennep@yahoo.com.br.
^IVPhd in Nursing, Assistant Professor, Nursing Department at the Federal University of Ceara, Researcher of the Coordination for Improvement of Higher Education Personnel, Fortaleza, Ceará, Brazil, Email: escolpaz@yahoo.com.br.
^VNurse. Doctoral Student in Nursing from the Federal University of Ceara Grant holder of the Coordination for Improvement of Higher Education Personnel, Fortaleza, Ceará, Brazil, Email: cfamerico@yahoo.com.br.
^VINurse, Master's Student of the Federal University of Ceara, Fortaleza, Ceará, Brazil, Email: carla_suellen@edu.unifor.br.

ABSTRACT: In addition to a leading position on infant’s nutrition, breast milk acts as an immunizing agent due to the absence of allergenic factors and the presence of maternal antibodies and of substances that ensure better digestibility. This research aimed at identifying the prevalence of the nursing diagnosis: ineffective breastfeeding in nursing mothers. Cross-sectional and descriptive study conducted with 95 nursing mothers assisted in basic health units of the 6th Regional Office of Fortaleza, Ceará, Brazil. Data was collected through interviews with a structured questionnaire, during mothers’ attendance to the health service to monitor the infant, from October to November, 2011. Nursing diagnosis was determined in 80 (84.2%) of the breastfeeding women. This percentage is quite high, given the increase in campaigns to encourage breastfeeding. We suggest that the nursing staff develop new guidelines for the care of nursing mothers, in addition to strategies to reduce this prevailing Nursing Diagnosis.

Keywords: Breastfeeding; nursing diagnosis; infants; breastfeeding women

INTRODUCTION

The probability of Brazilian children being exclusively breastfed up to six months of life is only 9.3% in the whole country. In the Northeast Region, this rate is even lower, corresponding to 8.4% and, in Fortaleza, capital of Ceara, this rate is below the Northeast Region rate, which is 6.4 %. With regard to the prevalence of exclusive breastfeeding (EBF) in children younger than six months of life, this is 41% of all Brazilian state capitals and the Northeastern Region had the lowest value corresponding to 37.0 %. In Ceara, however, the prevalence of the EBF until four months of the child's life went from 55.6 %, in 1999, to 71.1 %, in 2009, showing a growth of 28% in 10 years. In Fortaleza, in the same period, this rate was 32.9%¹. It is observed, therefore, that the municipalities of interior seem to leverage as well as the prevalence of EBF than the capital and that the sorrow of breastfeeding promotion, based on national policies and intentional, breastfeeding rates and EBF, in Brazil, are below the recommended².

Reasons for the decline of breastfeeding are imprint socio economic and cultural, highlighting the insertion of women in the labor market. The labor law no. 11.770, published in September 9, 2008, encourages companies to extend the maternity leave of the nursing mothers for 6 months, however, many of them have not yet embraced this new conduct³.

In this context, this study sought to answer the following questions: What is the prevalence of this ineffective breastfeeding nursing diagnosis (ND)? What are the main defining characteristics and related factors present in the studied group? Therefore, we aimed to assess the prevalence of ineffective breastfeeding ND and identify the defining characteristics and factors related to the more prevalent ND.

THEORETIC REFERENTIAL

Breast milk in addition to being the most complete food for the baby it acts as an immunizing agent due to the presence of maternal antibodies, absence of allergenic factors and substances which give better digestibility, being that the EBF an important indicator of the health of children³.

The breastfeeding promotion actions should be triggered, predominantly, by teams of family health strategy (FHS), in which are entered the nurses, who must develop in addition to educational activities addressing the superiority of breast milk and the mode of breastfeed effectively, monitor the nursing mothers and, thus, establish the nursing ineffective breastfeeding (ND) diagnosis as early as possible, to generate greater chances of success the nursing interventions. Therefore, the nurse has knowledge and ability to exercise rationality appropriate clinical care for the needs of mothers, which is possible through the systematization of nursing care (SNC).

The SNC has a holistic approach and consists in an organized manner and planned to guide the actions and the nursing care in order that the client's individual needs can be met, in addition to preventing possible aggravations, having been regulated by COFEN Resolution no. 358/20094. In spite of the SNC be presented, in general, with the steps of survey data, establishment of nursing interventions and evaluation of nursing outcomes, this study will focus the first two.

Ineffective breastfeeding consists in the identification of problems presented by mothers who have already experienced the breastfeeding, having as defining characteristics: lack of response to the other measures of comfort, absence of observable signs of release of oxytocin, the child cries to be put on the chest, the child cries or displays agitation in the first hour after the feeding, the child if archaeal on the breast, discontinuity of sucking on the breast, insufficient emptying of each breast by breastfeeding, inability of the child to grasp the nipple-areola region correctly, insufficient opportunity to suck the breast, persistence of sore nipples after the first week of breastfeeding, breastfeeding process unsatisfactory, resistance of the child in apprehending the areolar region-nipple with their mouth, observable signs of inadequate intake by the child, inadequate supply of milk and perceived inadequate milk supply; and as related factors: maternal ambivalence, anomaly of baby, anomaly of breast, maternal anxiety, previous breast surgery, the child receives supplementary feeding with bottles, knowledge deficit, lack of family support, prior history of failure in breastfeeding, interruption in breastfeeding, lack of support from the partner, prematurity and child's sucking reflex is unsatisfactory⁵.

The identification of the defining characteristics and related factors is carried out by means of survey data (interview and physical examination) with the mother, being preliminary step to the establishment of, which will underpin the implementation of planned interventions and, therefore, with high probability of effectiveness.

METHODOLOGY

Transversal and descriptive Study, developed in six basic health units (BHU) of Regional Executive Secretary (RES) VI, which make up the Health Care System of the City of Fortaleza, State of Ceara, Northeast Brazil. The RES VI, that is the largest, among the regional, assisting 29 neighborhoods, which corresponds to 42% of the territory in Fortaleza. The choice of RES VI as a scenario for the study occurred in virtue of being the space bound the practical training of nursing students from the University of Fortaleza (UNIFOR).

There were 95 participant nursing mothers who were being accompanied by FHS teams in the aforementioned RES, in the period from October to November 2011. The sample size was calculated by adopting a confidence coefficient of 95% (Zα = 1.96), population (N= 7750), which corresponds to the number of live births for May 2010 the may 2011, according to the Primary Care Information System of the Basic Attention (PCIS) of the Municipal Health Department (MHD) in Fortaleza; random error of 10% and a prevalence of 50%.

The nursing mothers were selected consecutively to the extent that they were seen at the BHU for a childcare consultation of the newborn. Women were included that met the following criteria: being monitored by the FHS teams of that RES, be breastfeeding and whose infants were less than six months.

The data were collected through interviews that followed a structured form, containing questions on demographic, socio-economic aspects and obstetric nursing mothers, as well as questions to the process of breastfeeding with focus on defining characteristics and factors related to the ND under study. Demographic and socioeconomic data included: age, education level, number of people in the family, family income, occupation and condition of union. The obstetric data spanned parity, number of abortions and type of the last delivery.

In this study it was determined in accordance with the presence of major defining characteristics: inadequate supply of milk, real or perceived, inability of the baby to grab correctly the womb of the mother, absence of observable signs of release of oxytocin, observable signs of inadequate intake of the child, not sustained suction to the bosom, insufficient emptying of each breast in each breastfeeding, persistence of sore nipples beyond the first week of breastfeeding, the baby demonstrating concern and crying in the first hour after the breastfeeding; not responding to other measures of comfort, the baby arching and crying with the breast, resisting the breast. The presence of one or more of these defining characteristics is sufficient to establish the diagnosis in study⁶.

In addition, the related factors investigated were: inverted nipples, reflected in lower milk inappropriate, prematurity, maternal anxiety, ambivalence, multiple pregnancies, maternal history of breastfeeding unsuccessful, lack of support from the partner and the family and lack of knowledge. The women were motivated to talk about the difficulties in breastfeeding and from there were being checked the defining characteristics and related factors.

The data were organized in the Excel program, version 2007. For quantitative analysis was used the software Statistical Package for the Social Sciences (SPSS) version 16.0. In the exploratory analysis, we calculated the absolute frequencies and percentages for the nominal variables. In the case of quantitative variables, were presented mean and standard deviation.

We followed the recommendations of Resolution no. 196/96 of the Ministry of Health National Council⁷. This project was approved by the Ethics Committee in Research of the University of Fortaleza (UNIFOR) as Protocol No. 277/2011. The participants signed a consent form after receiving the relevant information.

RESULTS AND DISCUSSION

The age of the interviewees ranged from 14 to 41 years, with an average 26.47 years, SD 7.27 years. Despite the predominance of nursing mothers in young adult and adult phase, 58 (61%), it must be emphasized that the set of nursing mothers adolescents, corresponding to 22 (23.2%) and nursing mothers in reproductive age in which there is high risk, totaling 15 (15.8%), as shown in Table 1.

The instruction of the subjects ranged from no schooling to higher education, predominantly the middle school between 43 (45.2 %) mothers. The number of people in the family ranged from 2 to 15, with an average of 4.60 and a SD of 2.14, according to Table 1. Family income ranged from R $ 272.50 to R $ 2,180.00 with an average of R $ 777.85 and a DP of 444.88, more prevalent income of R $ 545.00 (minimum wage during the study period).

The occupation of 57 (60 %) nursing mothers corresponded to the home activity, while 38 (40 %) worked outside of the home. As to the condition of their union, 74 (77.8 %) were married or lived in consensual union.

There was a higher prevalence of primiparous, corresponding to 44 (46.4%) interviewed, following the primiparas and multiparous women with equal percentages, statistically. With regard to the history of abortion, 70 (73.6 %) interviewed never suffered an abortion. About the delivery, 63 (66.3 %) women had their newborns by means of cesarean delivery, as can be observed in Table 2.

The ineffective breastfeeding ND prevailed in 80 (84.21%) nursing mothers in the sample, given that they had at least one of the major defining characteristics as inadequate milk supply, real or perceived, inability of the baby to grab correctly the womb of the mother, absence of observable signs of release of oxytocin, observable signs of inadequate intake of the child, not sustained suction to the bosom, insufficient emptying of each breast in each breastfeeding, persistence of sore nipples beyond the first week of breastfeeding, the baby demonstrating concern and crying in the first hour after the breastfeeding; not responding to other measures of comfort, the baby arching and crying with the breast, resisting the breast. While the other 15 (15.79 %) did not show any of these characteristics. This prevalence demonstrates the need for the FHS teams and, in particular, the nurse establish strategies that prioritize the incentive to breastfeeding, aiming to decrease this prevalence.

Other defining characteristics and related factors, presented in Table 3, reinforce the presence of the said ND the target audience of the research. Among the most cited are: breast milk is sufficient to satisfy the baby in that 63 (66.3 %) interviewed reported that not I satiate; 57 (60.0 %) mothers do not leave the baby drain the sinus completely during the breastfeeding; and 53 (55.7 %) mentioned that the baby is restless and/or cries after breastfeeding.

The remaining characteristics: inability of the baby to grab correctly the womb of the mother, absence of observable signs of release of oxytocin, observable signs of inadequate intake of the child, not sustained suction to the breast, persistence of sore nipples beyond the first week of breastfeeding, the baby arching and crying to the breast, resisting the breast, were less present in the group studied.

According to the factors related to the difficulty of sugar, the most frequently mentioned were: inverted nipples - 7 (7.4 %); reflex in the descent of inadequate milk - 2 (2.1 %) and prematurity - 1 (1.1 %). The associations maternal fatigue, maternal anxiety, maternal ambivalence, in the case of multiple births, inadequate nutritional intake, inadequate intake of liquids, history of breastfeeding unsuccessful, lack of support from the partner or family and lack of knowledge were absent in the majority of the nursing mothers. The breastfeeding interruption factor is secondary to sick mother, which appeared in 2 (2.1%) women and sick children in 6 (6.3%) of the interviewed nursing mothers.

It is known that the interruption or continuity of breastfeeding is related to biological, socio-economic and cultural factors. Thus, the results found in this study were compared with studies carried out in Brazil.

Other studies were concordant in relation to the average age of nursing mothers. A Study conducted with 266 nursing mothers, attended in two hospitals in Rethymno, found predominance of women in the age range between 20 and 29 years of age⁸. In another research conducted with 124 nursing mothers, answered in a hospital and in an outpatient nursing care the puerpera, located in Sao Paulo-SP, they also were in the age range of 20 to 29 years of age⁹. This means that the women of this study and of the surveyed studies are to breastfeed, predominantly, in age that does not represent a risk factor for breastfeeding ineffective, which is the age of adolescence.

In this study, were found 22 (23.2%) lactating adolescents, the age group with the greatest chance of ineffective breastfeeding due to physiological and emotional immaturity8. Children of women younger than 20 years of age have a 2.2 times greater risk of being weaned early when compared to children of mothers with age between 20 and 34 years¹⁰. Therefore, the age variable should be monitored in the ND context in study.

There was a predominance of nursing mothers with high school 43 (45.2 % ). In a study conducted with 266 mothers in Vicosa-MG, Brazil, this level of schooling was much higher, corresponding to 74% of the nursing mothers⁸. This finding confirms the prevalence of low education levels among women of the Northeast Region¹.

It is known that low schooling is a determinant factor of practice and continuity of breastfeeding⁸. Women with more schooling breastfeed their children longer¹¹. Therefore, the variable schooling should be taken into consideration in the assessment of this, and in the guidelines of nursing related to handle correct, that influence the infant's suction and, therefore, in the prevalence of ineffective breastfeeding.

Regarding the number of people in the family and family income, in this and other studies, concordant results were observed. In a qualitative study, conducted with 11 mothers who weaned their children early (before 6 months of age), in the northern part of the municipality of Teresina-PI, 72.7% had an income of up to one minimum wage¹¹. Another study conducted with 203 mothers, workers of a textile industry in Fortaleza-CE, all the women had a family income of up to one minimum wage¹². The precarious life conditions and low-income large families are associated with the interruption of exclusive breastfeeding¹³.

Qualitative Research performed at the Center for Family Development (CEDEFAM), in Fortaleza-CE, with 12 nursing mothers, observed that the economic factor is one of the most important in the success of breastfeeding, as the economic situation of a woman can have a significant effect on their physical and emotional well-being. Exclusive breastfeeding is positively associated with the socioeconomic status; there is no view that she was identified among women with higher income and schooling¹⁴. Another study identified that the early interruption of breastfeeding was associated (p= 0.035) to people with low socio-economic conditions¹⁰.

There was a predominance of lactating women who devoted themselves to home activities, represented by 57 (60.0 % ). A similar result was found in a study conducted with 40 mothers in the FHS of Goiania-GO, when 55% devoted themselves to this activity¹⁵. Meanwhile, 38 (40 %) worked outside the home. The occupation work outside the home corroborates the presence of ineffective breastfeeding. The study states that working outside the home is an impediment or obstacle to breastfeeding. The women who work in informality interrupt breastfeeding still more early, once that did not receive any social benefits and return to work even before the 30^th day after delivery³.

There was a predominance of consensual union or married, corresponding to 74 (77.8 %) mothers. Similar Percentages of consensual union was observed in a study conducted with 40 mothers in the FHS of Goiania-GO, when 82.5% lived in consensual union¹⁵. The study reports that there is an association (p= 0.017) between the father residing with the child and a longer duration of breastfeeding¹⁶.

In this study, there was a predominance of primiparity, corresponding to 44 (46.4 %). A similarly, in a study conducted with 58 mothers n the BHU in Marilia-SP, 64 %, the majority, were primiparous¹⁷. Study affirms that primiparity is a risk factor for early weaning due to lack of previous experience¹⁸.

In accordance with the type of the last delivery, 63 (66.3 %) delivered by cesarean section, a result similar to that found in a study conducted with 40 13983/08 in ESF of Goiania-GO, where 65% had cesarean delivery in last pregnancy¹⁵. A Study conducted with 8,397 mothers, in 47 maternity units (municipal, federal, military, state and private) in Rio de Janeiro - RJ, identified that the cesarean delivery was responsible for reducing by half the prevalence of breastfeeding in the first hour of the baby's life¹⁹. Thus, the study should be particularly investigated in lactating women who perform cesarean delivery, because this factor determines a delay of initiation of breastfeeding, causing anxiety and insecurity for the lactating mother and negatively influencing breastfeeding¹¹.

It was found in this study a high prevalence of ineffective breastfeeding (84.21 %) among mothers. This negative result contrasts with the increase of incentive programs to breastfeeding recommended by the Ministry of Health, between them, the creation of the 10 steps to successful breastfeeding²⁰.

In the above-mentioned study and conducted in the city of Marilia-SP, with 58 nursing mothers, it was found that 64% had the ineffective breastfeeding (the majority, converging to the result of the present research) and 18% had stopped breastfeeding or not able to start this practice¹⁷. Another study conducted with 40 mothers, in the area of coverage of the team of the FHS of Sanitary District East of Goiania-GO, found a prevalence of 87.5% of breastfeeding ineffective, corroborating the findings of this study¹⁵. With these results it is possible to realize that even in different regions of Brazil the diagnosis presents similar prevalence rates, hence the importance of a greater attention on the part of health professionals, especially nurses, who have a key role in changing this condition.

Study conducted at UBS in Marilia-SP, with 58 nursing mothers, found as main defining characteristics associated with the ineffective breastfeeding, the persistence of sore nipples in 12 (20 %) nursing mothers and the inadequate supply of milk present in 10 (20 %) women¹⁷. Research on breastfeeding practice in puerperal women, performed at a private health institution of Sao Paulo-SP, mentioned that 41% of women claimed that the breast milk was insufficient for the baby²¹. In this study, 63 (66.3 %) mothers also made the same claim. In 53 (60.0%) nursing mothers in this study the characteristic of not leaving completely empty the breast during breastfeeding. The study conducted in a joint lodging unit in São Paulo-SP, with 124 nursing mothers, highlighted as the main defining characteristic associated with the ND insufficient emptying of each breast, present in 100% of the nursing mothers⁹. Another study in UBS Marília-SP, Brazil, with 58 nursing mothers, found this same characteristic present in 6 (11%) of the women interviewed¹⁷. It is worth pointing out that by not leaving the completely breast empty, during breastfeeding, engorgement can occur, causing pain, which leads the woman to not wanting to breastfeed their baby anymore⁹. The mothers in this study, 53 (55.7 %) reported that their babies were weeping and/or were restless after breastfeeding. Surveys show that the mother associates the baby's crying to weak milk or insufficient, as well as considers that the initiative to offer liquids the child, by influence of family, initiative the interruption of exclusive breastfeeding¹¹.

It is observed that the presence of features highlight is related to myths and beliefs about the nutritional value of breast milk, which contributes to the early weaning²².

CONCLUSION

The researched showed a prevalence of 80 (84.21 %) among mothers. Therefore, indicates a predominate nursing problem in this group, requiring actions to control the associated factors. In this context, it should be highlighted that the defining characteristics present provide a direction for the establishment of goals and specific actions and, consequently, evaluation of the assistance provided. Given the findings, it is necessary that the nurse will strengthen the guidelines about the benefits of breastfeeding during the pre-natal care and build support groups breastfeeding mothers for that can be minimized to ineffective breastfeeding and reduced the early weaning.

Among the limitations faced in the study, the main were: scarcity literary about this diagnosis in study with mothers, which makes the comparison of findings with other authors and have used the process of Carpenito-Moyet for evaluation of the presence of the diagnosis, because the author is based on the presence of major defining characteristics for the establishment of a diagnosis, a parameter that is currently being replaced by measures of accuracy and some statistical tests to establish the presence of the nursing diagnosis. The majority of studies found was also developed with women in immediate puerperium, not being assessed the continuity of exclusive breastfeeding until the sixth month of life.

It is suggested that future studies with mothers who are not only in the immediate puerperium, as also with mothers who are in the process of breastfeeding until the sixth month of life of the infant. It is recommended to review the accuracy of their clinical indicators of independent pre-definition of characteristics that determine the presence of diagnosis, as well as studies that incorporate the identification of factors related to this diagnosis.

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