ORIGINAL RESEARCH

Difficulties in establishing breastfeeding: view of nurses working in primary care facilities

Carmen Carballo Dominguez^I; Nalú Pereira da Costa Kerber^II; Jamila Vasquez^III; Lulie Odeh Susin^IV; Taimara Martins Pinheiro^V; Eloisa da Fonseca Rodrigues^VI

^I Master in Nursing. Member of the Viver Mulher Research Group. Federal University of Rio Grande. Nursing School. Rio Grande do Sul, Brazil. E-mail: carmencbdm@gmail.com
^II Ph.D. in Nursing. Leader of the Living Women Research Group. Federal University of Rio Grande. Nursing school. Rio Grande do Sul, Brazil. E- mail: nalukerber@gmail.com
^III Ph.D. student in Health Sciences. Member of the Research Group on Living Women. Federal University of Pelotas. Pelotas, State of Rio Grande do Sul, Brazil. E-mail: jamilavrock@gmail.com
^IV Ph.D. in Child and Adolescent Health. Member of the Living Women Research Group. Federal University of Rio Grande. Faculty of Medicine. Rio Grande, Rio Grande do Sul, Brazil. E-mail: susin@mikrus.com.br
^V Master student in Nursing. Member of the Viver Mulher Research Group. Federal University of Rio Grande. Nursing school. Rio Grande do Sul, Brazil. E-mail: taimaramp@gmail.com
^VI Ph.D. student in nursing. Member of the Living Women Research Group. Federal University of Rio Grande. Nursing school. Rio Grande do Sul, Brazil. E-mail: eloisadafonsecarodrigues@yahoo.com.br

DOI: http://dx.doi.org/10.12957/reuerj.2017.14448

ABSTRACT

Objective: to examine the difficulties in establishing breastfeeding, from the perspective of nurses in the primary health care system in the town of Rio Grande, Rio Grande do Sul. Method: in this qualitative study, 47 nurses in Rio Grande were interviewed in 2012. Data were analyzed on the basis of Collective Subject Discourse. The study was approved by the health research ethics committee of Rio Grande Federal University (opinion No. 184/2011). Results: analysis identified four central ideas: PHC nurses are unprepared to give mothers proper guidance on breastfeeding; women's beliefs and participation in social networks may contribute to early weaning; use of feeding bottles and pacifiers interferes with breastfeeding; and inappropriate technique has negative effects and interferes with efforts to establish breastfeeding. Conclusion: community beliefs, outdated skills, and inappropriate technique influence breastfeeding-related behavior.

Keywords: Breastfeeding; nursing; primary health care; health education.

INTRODUCTION

In Brazil, breastfeeding levels have increased over the decades but still fall short of recommendations from the world´s organizations. Data from the National Demographic and Child Health Survey¹ show that, although 96.4% of all mothers report that their children were breastfed at least once, only 40% of the babies received exclusive breastfeeding until six months old. In the II Maternal Breastfeeding Prevalence Survey ², there was an increase in the duration of exclusive breastfeeding (EB), from 23.4 days in 1999 to 54.1 days in 2008, as well as in the median duration, which increased from 295.9 days in 1999 to 341.6 days in 2008.

In the prevalence of exclusive EB by age in regions of Brazil, in the Southern Region of the country, the research showed that only 24.5% of the children received breast milk with 120 days of life, falling to 9.9% with 180 days².

As a strategy to strengthen support for the practice of breastfeeding, Rede Amamenta Brasil was created in 2008 to increase breastfeeding rates in the country. From the circulation and exchange of information, it guides the training of professionals who work in the Basic Health Units (ABS) so they are agents of change in the teaching and learning of the EB, considering the importance of these professionals who are in a unique situation being closer to the reality experienced by the families^3,4.

In view of the aspects addressed, the relevance of the assistance provided by ABS, the importance of the professional in this reality and the difficulties faced by the women and pointed out by the nurses, this study answers the following question: What are the main difficulties for establishing the EB, from the perspective of nurses working in the context of ABS?

Thus, the objective is to know the difficulties for the establishment of Breastfeeding from the point of view of the nurses of the Basic Network of Health Care in the city of Rio Grande - RS.

LITERATURE REVIEW

The advantages that breastfeeding brings to the mother, the newborn (NB) and society are undeniable, knowing that this practice could prevent more than 6 million deaths of children under 12 months old each year around the world¹. Breast milk is the main food for children in the first six months of life, rich in nutrients and recommended as the only food to be offered in this period^3-5. However, it is known that the interruption or continuity of breastfeeding is related to biological, socioeconomic and cultural factors^6,7.

Early weaning can be interpreted as a result of the complex interaction of several factors related to the social and cultural diversity being part of women´s lives, such as: structural changes in society; the insertion of women in the labor market; the emergence and propagation of industrialized milks; the routines, in the health institutions that are not a facilitator of the EB; and the adherence of health professionals to the prescription of artificial feeding⁸.

When support for breastfeeding is not shifted to the mother-child dyad and to the social, political and economic context of the society in which it is inserted, it can be considered that the causes of interruption or even denial of breastfeeding are circumscribed by the allegations such as weak milk, little milk, dried milk or even the disinterest of women⁸, but this condition needs to be reviewed.

Allying emotional support with information about correct breastfeeding practices for mothers who are breastfeeding may result in more effective interventions in encouraging breastfeeding⁹. Considering that the primary level of public service assistance is largely responsible for the prenatal care and childcare, it is essential to know the difficulties faced by the professional in establishing the EB⁵ and it is clear that there is a need for permanent training so new concepts based on scientific evidence are assimilated and disseminated⁹.

METHODOLOGY

This is a study with a qualitative approach. Data from the research entitled "Breastfeeding: Knowledge and management of professionals of the Basic Health Network in a municipality in the extreme south of Brazil" held in 2012 were compiled.

The context was the Basic Health Units (BHU) of the urban area of ​​the municipality of Rio Grande, located in the extreme south of Rio Grande do Sul, which has a network of 34 UBS and 19 of them with Family Health Strategy (ESF). There were 47 nurses interviewed who worked in these units, 22 of the ESF and 25 of the traditional units. Professionals did not participate in the study on vacation or on any type of leave at the time of collection.

The data collection was developed through an individual interview in the UBS, and the nurses were questioned about the difficulties they felt for the establishment of the EB in the patients assisted in the health unit. The interviews were transcribed, coded and the resulting data were interpreted through the Collective Subject Discourse (CSD)¹⁰. This technique seeks to reconstitute a collective opinion by the aggregation of statements, in a discourse-synthesis of the individual statements that present similar or complementary meanings. In this way, the collective subject is expressed through a discourse emitted in what could be called the first "collective" person of the singular¹⁰.

The CSD analysis applies very well in qualitative studies, since the intention of its use is that the answers to the applied questions are reconstructed, with pieces of individual speeches and, from the junction of answers, will generate as many speeches as they are necessary to express a given social thought or representation about a phenomenon.

Discourses pass through content analysis, with decomposition into the main central ideas present in each one, after being all gathered, constructing a synthesis that aims at the discursive reconstitution of social representation.

The following steps were necessary to obtain the CSD: ​​reading the response of each question, marking the selected key expressions; identification of which were the central ideas of each answer; analysis of all key expressions and central ideas, grouping the like into clusters; identification and naming of the central idea of ​​the whole, which was a synthesis of the central ideas of each discourse; construction of CSDs through the introduction of connectives, which provided the cohesion of discourses ("thus", "finally", and others); the speech was written with verbs in the first person singular, as the technique calls for, to suggest a collective person speaking, as if it were the individual subject of the speech.

Discussion of the data was based on the findings found by authors of the area and the guidelines of the Ministry of Health, which are included in Basic Care Booklet nº 23: Infant Nutrition Breastfeeding and Complementary Feeding³. The research was approved by the Committee for Ethics in Research in the Health Area, Federal University of Rio Grande, with Opinion Nº 184/2011.

RESULTS AND DISCUSSION

The emerging discourses after the transcription of the data allowed the presentation of four Central Ideas (CI), which reflect the difficulties faced by professionals to establish the EB:

CI: Basic Health Units: Nurses are unprepared to properly guide mothers for Breastfeeding.

CSD: I think the main fault is in the prenatal, in which it is necessary to prepare the mother because it has wrong information and mismatch. If there was a different prenatal care, it would be much better. The professionals are not prepared, even because they lack training. It has little information, in college it does not have so much information and it does not have a specific program of breastfeeding in the Basic Health Unit and in some stations, there are no puericulture consultations.

Nurses´ settings reflect anxieties regarding the aspects that hinder to establish EB. The lack of guidance to professionals acts as a negative factor since the information obtained during graduation¹¹ are not enough and the qualifications during the professional life are insufficient or nonexistent.

In view of the lack of adequate support information and the insecurity indicated by the nurses, they are in an unfavorable position to guide and interact with a community that is deeply rooted, often in the culture of weak or insufficient milk, for example. Factors associated with poor information by the mothers and the lack of standardization in the implementation of programs and access to the health system, act as precipitants of early weaning and do not meet health policy objectives in serving the patient within their needs³.

Carrying out prenatal care with poor guidance, poor counseling, and no dedication to working with their fears and anxieties do not provide a supportive environment for women´s support¹². The lack of specific programs for the promotion of EB and the lack of childcare in some units also exert an unfavorable influence. Caring for this type of care is the role of nurses and physicians working in primary care and its practice favors the care and assistance appropriate to the needs of the woman and the NB.

CI: Beliefs and participation of women´s social network can contribute to early weaning.

CSD: Relatives, especially the grandmother, are very resistant, have a lot of beliefs and myths that pass to the mother and offer little clothes, putting down everything that was oriented during prenatal care. It is difficult to educate the mother to only breastfeeding, not needing to supplement even with water. The mother is terrified, does not know the technique, does not adhere, hence the milk does not go down. She thinks that she is weak, she thinks that she does not have enough milk and she is not willing, without patience, they work and do not want to breastfeed, from there they mix the milk: milk of the breast and of a cow. The mother has the desire to go out alone and leave the baby, they leave someone with the bottle and leave. The mother becomes very tired and there is resistance from the family culture and the social network that interferes.

Fator apontado pelas profissionais como corroborantes ao desmame precoce diz respeito à rede social que cerca a mulher, formada pelos seus familiares, vizinhos e pessoas próximas. Cabe ao profissional de saúde estar preparado para agir na interferência desta rede, o acolhimento precisando ser estendido ao núcleo familiar, pois o seu trabalho de promoção e apoio ao AM necessita de um olhar atento, abrangente, sempre levando em consideração os aspectos emocionais, a cultura familiar, a rede social de apoio à mulher, entre outros^13-15. As pessoas mais experientes, em especial familiares, exercem influência importante nas condutas relacionadas à amamentação. Não basta a mulher querer amamentar, ela necessita de apoio para ser compreendida na particularidade de sua realidade sociocultural^13,14.

Factors pointed out by professionals as corroborating to early weaning concern the social network that surrounds the woman, formed by her relatives, neighbors and close people. It is up to the health professional to be prepared to act in the interference of this network, the host needing to be extended to the family nucleus, since their work of promoting and supporting the EB needs a careful, comprehensive view, always considering the emotional, family culture, the social network to support women, among others^13-15. More experienced people, especially family members, have an important influence on breastfeeding behaviors. It is not enough for a woman to want to breastfeed, she needs support to be understood in the particularity of her socio-cultural reality^13,14.

Other factors that may also influence the effective establishment of the EB are the burden of triple work hours, often assumed by the woman: mother, housewife and paid worker^11-14. They are considered factors that can be precipitating of early weaning, as well as corroborating the experiences by women, their perceptions about breast milk and about themselves as nursing mothers, besides the insecurities and difficulties faced in the practice of the EB.

When these factors are not covered, it is possible that there is a loss in the breastfeeding process, in the duration of the breastfeeding process, since the woman starts to feel alone. Encouraged mothers with adequate family and professional support are more likely to successfully breastfeed and there is a correlation between the intentions of the pregnant woman to breastfeed her child and the duration of breastfeeding⁶. In this condition, the role played in the practice of Child Care in the Basic Health Units is fundamental, since this care represents an important moment of knowledge and discussion of family beliefs and customs.

CI: The use of bottle and pacifier interferes with Breastfeeding.

CSD: With the use of the bottle, the baby makes less effort to suckle, the handle is different, it has suctioning facility, so he can prefer the bottle rather than the breast and the beak is more open and it facilitates the milk fall in the mouth and can reject the breast that is harder for the milk to leave and still fails to exercise the muscles, this interferes with the teeth and the oral anatomy, will leave the arcade prominent. The bottle may cause some infection if it is not thoroughly cleaned, sanitized. Also, as the baby suckles less, it decreases demand and will decrease milk production and may lead the mother to think that her milk is weak because the child prefers the bottle. Giving the bottle can be more comfortable for the mother since someone else can give, hence has no affection between the two, breaking the bond that is important. The bond is also affected by the use of the pacifier because when the baby uses pacifiers always sucking and he will not need to suck the breast.

Literature is abundant in pointing out that there is evidence that bottle-feeding is associated with early weaning and increased infant morbidity and mortality since it is an important source of contamination^3,16,17. Also, some children have difficulty breastfeeding ¹⁵ after experiencing the bottle. This difficulty is referred to as "nozzle confusion"¹⁷, which is generated by the difference between sucking on the breast and the bottle.

The bottle offers an easier suction for the child, because milk flows abundantly, which justifies their preference for it. The reflex of breast milk ejection is more time-consuming at the beginning of the feeding, requiring more effort by the newborn. The fact that the child receives milk through the bottle directly influences the production^3,19 of breast milk since the decrease in demand causes the maternal neural reflexes to decrease, leading to lower milk production¹⁹. The lower the stimulus, the lower the milk production and the greater the supply of bottle, which leads to weaning.

Also, the type of suction performed on the bottle determines how the dental arch will form, leaving it more protruding, and improves maturation of the facial muscles, as the ease of extraction of the milk leads to less effort. In this way, the child who receives milk in the bottle may present deviations in the formation of the dentition and the bones and muscles involved in speech and chewing¹⁶.

The use of bottles and pacifiers are corroborated as a negative influence on breastfeeding in the nurses´ discourse. It is necessary to disseminate the Brazilian Standard for the Marketing of Foods for Infants and Young Children, Nozzles, Pacifiers, and Bottles for women not to use these devices, so they can understand the appropriate way to stimulate breastfeeding and the needs of their children.

Children who use pacifiers, in general, are also breastfed less often, which compromises milk production. It is proven that early weaning occurs more frequently in children who use pacifiers¹⁶. It is possible that using a pacifier is a sign that the mother is having difficulties in breastfeeding or she is less willing to breastfeed. Besides to interfering with EB, its use is associated with a higher occurrence of oral candidiasis, and to other diseases such as otitis media and palate alterations^3,16.

Another important factor to be considered during the practice of EB is the feelings experienced by the mothers, which may influence their willingness to give the baby a bottle. With its use, the mother is freer from this demand, with the possibility of performing other daily tasks, since other people will be able to feed her child²⁰.

In a study carried out in the municipality of Jequié, Bahia, with five mothers accompanied by the Family Health Strategy, their speeches showed how much the woman needs to be available in full so the baby can suckle. This fact competes in a negative way with the other tasks of her life, whether in the role of housewife, outside worker, mother of other children and wife. This is a situation that often means experiencing tiresome, painful moments with changes in mood²⁰. During the breastfeeding period, and especially in the beginning, the woman experiences several feelings and this makes it extremely important to accompany trained and safety professionals who serve as support.

CI: Inadequate technique has negative consequences and interferes with the establishment of Breastfeeding.

CSD: With the wrong handle, the baby does not gain weight, he gets below expectations and refuses the breast, crying very hungry, he is irritable at the time of suckling, and he has gas. Another thing that interferes is placing the baby on his belly, not keeping a comfortable position, not getting a fish mouth, not picking up the whole areola. If you make a noise during suction, you have a bad handle, sometimes he has choking and does not suck. Also, the mother with a scissor hand makes pinching of the breast, there is no emptying of the entire breast and there is engorgement. Fissure, mastitis, cut areola, cracked and inadequate posture of the mother are signs indicative of inadequate technique. The mother has pain when breastfeeding, she is not comfortable, she is nervous and she cannot put the baby to breastfeed and this can contribute to the delay in the milk going down.

The nurses indicate that the incorrect technique of breastfeeding is also a fact that can directly influence the effectiveness of the EB. Anxious, unprepared mothers who do not properly breastfeed the newborn are characterized as collaborative factors at early weaning.

Sugar originates from a reflex act. However, it is necessary to assist the NB for an adequate positioning in relation to the mother and, consequently, in relation to the breast and the act of suckling. In some cases, the fact of sucking and not gaining weight shows up as an incorrect catch signal³.

Correctly extracting milk involves factors such as how the mother and newborn position to breastfeed/suck and the correct breastfeed. They are very important aspects so the milk leaves in quantity and quality adequate to allow a good development of the NB and to avoid the common intercurrences in this phase like the engorgement, cracks, and mastitis. Besides hindering to take milk, the practice of an incorrect handle can lead to nipple injuries. When there is a good handle, the position of the nipple inside the child´s mouth protects it from friction and compression, thus preventing nipple lesions^3,19.

An aspect that interferes a lot in this adequate establishment of the correct handle is the position for breastfeeding, which, being not adequate, it makes breast emptying difficult, leading to a decrease in milk production. Often, the NB with an inadequate handle does not gain the expected weight despite remaining a long time in the breast^3,19.

The mother should choose the most comfortable, relaxed position. Important aspects to be observed such as the baby´s body that should be close to the mothers, all aligned and facing her, belly with belly and her head should be on the same level as the breast. It is not recommended that the mother´s fingers be placed in the form of scissors, as this may serve as an obstacle between the baby's mouth and the areola. The newborn should take the nipple and part of the areola with the mouth. It is necessary to observe if the mother feels pain when breastfeeding, in addition to realizing if the baby suffocates with the breast or makes high noises of suction because these factors are indications of inadequate handle³.

It is up to the nurses to be able to guide women to their needs and those of the newborn, as well as to aggregate the community that surrounds them. For this, a joint effort of the health system is necessary, with professional support to qualify for adequate assistance. These are important issues in ensuring that breastfeeding is experienced in a satisfactory and enjoyable way and, therefore, increases breastfeeding rates in the country.

CONCLUSION

The performance of this study enabled to know the difficulties faced by the nurses regarding the establishment of the EB. Based on the reports, it was possible to envisage how complex the assistance to women is to establish breastfeeding since it is necessary to support the health professional to strengthen it and support it in the challenges of decreasing early weaning rates.

These challenges include the beliefs of the community, the lack of updating of professionals, the use of pacifiers and bottles, inadequate technique and the woman herself, and the entire social network surrounding her, which have an important influence on breastfeeding-related behaviors. Thus, the educational actions of breastfeeding should be emphasized to professionals and women and the community at all levels of care, as well as adequate government policies and the support and participation of every society.

Initiatives to reduce early weaning rates require a joint effort since they cannot be isolated and the community that surrounds women, women and professionals must be involved in educational activities. Nurses need to discuss the aspects that permeate breastfeeding, promoting reflections on the reasons that make breastfeeding subject to various negative influences and enabling to solve the difficulties, since this practice should be lived in a quiet and pleasurable way.

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