RESEARCH ARTICLES

Comparison of the knowledge of postpartum women regarding breastfeeding

Mariana de Oliveira Fonseca-Machado^I; Marina Stark Rezende de Paula^II; Bibiane Dias Miranda Parreira^III; Juliana Stefanello^IV; Flávia Gomes-Sponholz^V

^I RN. Master’s Degree. University of São Paulo. School of Nursing of Ribeirão Preto. Nursing Graduate Program in Public Health. Ribeirão Preto, São Paulo, Brazil. E-mail: mafonseca.machado@gmail.com
^II RN. Universidade Federal do Triângulo Mineiro. Nursing Undergraduate Program. Department of Nursing in Community Health Education. Uberaba, Minas Gerais, Brazil. E-mail: ninastark@terra.com.br
^III RN. Master’s Degree. Universidade Federal do Triângulo Mineiro. Nursing Undergraduate Program. Department of Nursing in Community Health Education. Uberaba, Minas Gerais, Brazil. E-mail: bibianedias@yahoo.com.br
^IV RN. Ph.D. University of São Paulo. School of Nursing of Ribeirão Preto. Department of Mother-Child Nursing and Public Health. Ribeirão Preto, São Paulo, Brazil. E-mail: julianas@eerp.usp.br
^V RN. Ph.D. Lecturer. University of São Paulo. School of Nursing of Ribeirão Preto. Department of Mother-Child Nursing and Public Health. Ribeirão Preto, São Paulo, Brazil. E-mail: flagomes@eerp.usp.br

ABSTRACT

The purpose of this study was to compare the knowledge of postpartum women regarding breastfeeding according to sociodemographic, obstetric and personal aspects. This observational cross-sectional study was developed in the rooming-in of a university hospital in Uberaba, Minas Gerais, with 141 women, between July and August of 2010. Data were collected by means of interviews with a validated instrument. Data were analyzed using the univariate analysis, Student’s t-Test for differences between means and Pearson’s correlation analysis. The knowledge regarding breastfeeding was higher in the group of women with nine or more years of education, who attended six or more prenatal visits and received guidance on breastfeeding during pregnancy (p <0.05). Identifying the characteristics of women with greater knowledge on breastfeeding allows to propose educational programs and reorganize health services for the implementation of specific and targeted actions.

Keywords: Breastfeeding; knowledge; women; postpartum period.

INTRODUCTION

Breastfeeding is a safe source of nutrition for human beings in the initial phase of life. Its benefits have been well documented in the scientific literature and efforts to promote this practice are being implemented in several countries¹.

The World Health Organization (WHO) advises that human milk must be the only food in the first six months of life of a child and, after this period, it may be complemented with other food, nutritionally appropriate, until the child is two years or older. Despite this recommendation, national studies revealed that, in 2008, the median duration of exclusive breastfeeding (EB) in Brazil was 54.1 days, whereas the duration of complemented breastfeeding was 11.2 months².

The choice to breastfeed is something complex and involves the knowledge of women regarding this practice, which is permeated with biomedical and cultural concepts, values, beliefs, previous experiences and the interference of family members, community and health professionals³.

The identification of the knowledge of pregnant women and nursing mothers regarding breastfeeding and its determinants allows health professionals to make a new approach of breastfeeding, by entering the multidimensional complex that permeates this practice⁴. In addition, it contributes to reduce child morbimortality rates, as it interferes in the prevalence and duration of breastfeeding^5,6.

Over the last ten years, national^5,7-13 and international studies^14-16 have analyzed the knowledge of postpartum women regarding breastfeeding. These studies focused mainly on the description of this knowledge and its relationship with variables such as age, education, guidance, experience in breastfeeding, development of a family plan and number of prenatal visits.

However, the knowledge approached in studies developed in Brazil is restricted to punctual and specific questions in breastfeeding^8,9,13, leading to a gap in the national scientific production as for the identification of variables related with a knowledge that broadly comprises theoretical and practical aspects of breastfeeding.

In order to study this issue directly, the present study aimed to compare the knowledge of postpartum women regarding breastfeeding according to sociodemographic, obstetric and personal aspects.

THEORETICAL FRAMEWORK

Health promotion is a promising strategy to face health problems affecting individuals and their environment, as well as to achieve better life conditions in general. Its feasibility is granted by public policies, favorable conditions to the development of health and the reinforcement of the capability of individuals and communities. It is based on a broad concept of the health-disease process and its determinants, and proposes the articulation of technical and popular knowledge, reflecting a reaction to the growing medicalization of social life¹⁷.

Feeding and nutrition constitute basic requisites for the promotion of health, stating broadly the human potential for growth and development, with quality of life and citizenship. One of the most important occurrences in the Brazilian setting of feeding and nutrition is the continuing dissatisfactory breastfeeding rates, despite the increase observed over the last decades¹⁸.

Breastfeeding and, consequently, the knowledge of women regarding this practice, are developed within a sociocultural context. Actions in favor of breastfeeding, either individually or collectively, must take into consideration the combination of nature and culture that comprises this practice¹⁹.

In this sense, the identification of the knowledge of postpartum women regarding breastfeeding and its relation with sociodemographic, obstetric and personal aspects may be considered an action for breastfeeding promotion. From this point, other strategies such as public policies; programs; activities; the creation of favorable environments; qualification and information for mothers, parents, family members and communities; and the development of individual skills and pro-breastfeeding attitudes may be promoted, contributing to increase the prevalence and duration of breastfeeding in Brazil.

The promotion of breastfeeding aims to create cultural behaviors and values favorable to this practice, so that it may be assumed as a rule, which depends on national public policies and the recommendations of social and health services²⁰.

METHODOLOGY

This observational cross-sectional study was developed in the rooming-in of a university hospital in the municipality of Uberaba, Minas Gerais, Brazil.

Uberaba is located in the macroregion of Triângulo Mineiro and Alto Paranaíba, and it is the hub city of the health micro and macroregion of Triângulo Sul, comprising 21 municipalities.

The study sample comprised all postpartum women who were hospitalized in this rooming-in, between July and August of 2010, and accepted to participate in the study by signing the Free and Informed Consent Form (FICF). Minors were accompanied by an adult responsible for them, who approved their participation and signed the FICF. The final population totaled 141 women.

Data were collected by means of interview in the first 24 after the delivery, in a calm place and when the women presented appropriate physical and psychological conditions. After data collection, the difficulties and questions of the participants were clarified.

The public domain instrument used was previously tested and validated²¹, and comprised questions regarding the sociodemographic (age, education, marital status, occupation) and obstetric profile (parity) of the participants; the characteristics of the prenatal care received (number of prenatal visits, guidance on breastfeeding) and their personal experience in breastfeeding (time they breastfed previous children); and the identification of the women’s knowledge regarding breastfeeding.

In order to identify this knowledge, a test with ten true or false questions was used, contemplating the following aspects: self-care with their breasts, conduction of the feeds, ideal moment for the first feed, duration of EB and complemented breastfeeding, milk production, control of lactation and mammary complications. Each correct answer scored one point, so the maximum score was ten. Incorrect answers scored zero.

The variable answer considered was the mean of correct answers in the knowledge test. The explanatory variables were: the time they breastfed previous children, in months; and the sociodemographic, obstetric and prenatal variables, with yes or no answers.

Data were stored in an electronic Excel spreadsheet, and validated by means of duplicate typing. Statistical analysis was performed with the program Statistical Package for Social Sciences (SPSS), version 16.0. Data were presented as absolute and relative frequencies, and as for the quantitative variables, mean values (central tendency measures), standard deviations and minimum and maximum values (variance measures) were calculated. Bivariate analysis was used to identify the relationship between the variable answer and the explanatory variables. The summary measures (means of correct answers) were compared with the different groups of factors defined by the categorical variables, with the application of Student’s t test. Pearson’s linear correlation coefficient (r) was used in the analysis of the correlation between the mean of correct answers and the time of breastfeeding provided to previous children. Data normality was verified by means of the Kolmogorov-Smirnov test. The level of significance of the p-value, adopted for the tests, was α under or equals 0.05.

The research proposal was approved by the local Research Ethics Committee of Universidade Federal do Triângulo Mineiro (Process no. 1152/2008), as per resolution 196/96 of the National Health Council. The study was developed in compliance with ethical standards, respecting human dignity and the use of the FICF.

RESULTS AND DISCUSSION

Profile of the subjects

The age of the study participants varied between 12 and 44 years, mean of 24.7 (SD=6.5) years, with 118 (83.7%) of them being 19 years old or over. These data confirm the findings of studies developed in the states of Rio Grande do Sul²² and Ceará²³, in which the mean age of the women was 27.4 and 23.9 years, respectively. Another study developed in the same rooming-in as the present study¹², revealed that most of the postpartum women (89.6%) were over 18 years of age.

The studied group was made of 95 (67.4%) women who were married or lived with a partner. Studies developed in rooming-ins of two maternity hospitals in Fortaleza revealed that 80%23 and 75.8%7 of the interviewees were married or lived in common-law marriage.

Regarding education, 87 (61.7%) parturients had nine or more years of education. The participants of studies developed in Saudi Arabia¹⁴, India¹⁵, and in the Brazilian states of Minas Gerais¹², Ceará^7,9,23, São Paulo²⁴ and Mato Grosso¹¹ also stated they had studied for nine or more years. However, these findings differ from those identified in a study developed in two hospitals of Viçosa, Minas Gerais⁵, in which 78% of the participants had eight years of education or less.

As for their position in the work market, 83 (58.9%) participants did not have a paid activity and 58 (41.1%) were formally or informally employed. Similar results were found in studies developed in Ceará^7,25, Mato Grosso¹¹ and Bahia²⁶, in which most of the women (73%, 80%, 73% and 55.7%, respectively) did not perform any paid activity either.

As for prenatal care, 140 (99.3%) women stated they attended prenatal visits and, among those, 109 (77.9%) attended six or more visits, which is the minimum number of visits recommended by the Ministry of Health²⁷. Surveys developed in Minas Gerais⁵, Ceará^9,23 and Mato Grosso¹¹ evidenced that more than 90% of the women interviewed attended prenatal visits. On the other hand, in Saudi Arabia, a little more than half the participants received medical care during pregnancy¹⁴. A study developed in Rio Grande do Sul²² revealed that 71.7% of the women attended five or more prenatal visits.

From all the women who received prenatal care, 105 (75%) were guided as for breastfeeding in this period, a similar datum to that found in studies developed in Minas Gerais¹², Ceará²³, São Paulo²⁴, Saudi Arabia¹⁴ and Jordan²⁸. The authors believe that this situation represents, somehow, a limitation in the prenatal care offered, since it is expected that all women followed-up during pregnancy receive guidance regarding breastfeeding from health professionals, either individual or collectively.

It is important to highlight that the main source of guidance was the health professional, especially the nurse. In total, 70 (66.7%) participants were guided by this professional, whereas 30 (28.6%) received guidance from physicians, social workers and professors from courses in the health area. There were also 5 (4.8%) interviewees who stated they did not know the professional category of person responsible for this guidance. In Santo André, São Paulo²⁴, most (54.3%) of the participants stated that the professional responsible for guiding them was the nurse, which confirms the finding of the present study and reinforces the role of nursing in the promotion, protection and support to breastfeeding²⁹.

Regarding parity, 59 (41.8%) women were primiparous and 82 (58.2%) were multiparous. Among these, 69 (84.1%) had already breastfed and 13 (15.9%) had no prior experience. The total time through which these 69 women breastfed their children varied between one and 48 months, with mean of 15 (SD=1.1) months. A study developed in Viçosa, Minas Gerais⁵, showed that 59% of the women had more than one child. On the other hand, another study developed in a maternity hospital in Fortaleza, Ceará²³, verified that most (55.8%) of the participants were primiparous.
As for previous experience in breastfeeding, studies developed in Rio Grande do Sul²², India¹⁵ and Ireland¹⁶ evidenced that most of the women had already breastfed.

The mean time of breastfeeding provided to the previous children of the 69 (84.1%) women, participating in this study and who had prior experience, is distant from the time recommended by the WHO, which is two years or more of complemented breastfeeding. However, it exceeds the national mean (11 months) and that of the capital city of the state of Minas Gerais (10 months)2. In a study developed in the municipality of Horizonte, Ceará²⁵, the time of breastfeeding provided by the participants was nine months, which is less than that found in the present study.

Knowledge regarding breastfeeding

The comparisons between the means of correct answers in the knowledge test of the different groups, defined by the categorical variables, are presented in table 1.

The findings presented in table 1 provide evidence that studying for nine or more years (p=0.001), attending six or more prenatal visits (p=0.025) and receiving guidance regarding breastfeeding during pregnancy (p=0.044) increase the knowledge of women on the subject (p value=0.009).

A study developed in Fortaleza, Ceará, verified that women with eight or more years of education had a greater knowledge regarding the benefits of breastfeeding⁹. In Ireland, women with less knowledge on breastfeeding had lower educational levels¹⁶, whereas in India¹⁵ those with greater educational level had a higher score in the knowledge tests, which confirms the findings of the present study.

A lower level of education may be a risk factor to stop breastfeeding early, due to the limitation in knowledge and the poorer ability to understand and absorb, properly, the information received, complicating the effectiveness of educational actions^11,30,31. On the other hand, women with greater educational level, especially those with higher education, understand more easily the instructions received and are less influenced by the information of others, rejecting practices that are harmful to breastfeeding. In addition, a greater educational level generates self-confidence and security in women to deal with the common discomforts and complications in the lactation period^32,33.

owever, there are divergences in the scientific literature as for the association of the educational level and the prevalence and duration of breastfeeding, reinforcing the fact that the success of this social practice is associated with multiple factors, not only the number of years of education¹¹ .

A study developed in a public maternity hospital in Fortaleza revealed that, among the parturients with more than six prenatal visits, most of them answered specific questions regarding breastfeeding correctly, in the knowledge test9. Another study developed in Nigeria evidences that mothers with four or more prenatal visits were more likely to provide exclusive breastfeeding to their babies³⁴. In Minas Gerais, Brazil, women who received guidance on this matter had a greater chance of answering the question regarding poor milk correctly¹³. A community-based study developed in India¹⁵ revealed that women who received guidance on breastfeeding presented satisfactory knowledge regarding the subject, similar to the findings of the present study.

These findings suggest that health professionals are providing appropriate guidance on breastfeeding during prenatal³⁴. The attendance to six or more prenatal visits assure qualified and humanized care to the pregnant woman and offers important instructions regarding breastfeeding³⁵. Learning the aspects related with the breastfeeding practice is essential so that mother and child can experience this moment effectively and calmly, receiving necessary and appropriate information from the health professional, still during pregnancy³⁶. All pregnant women need information and support in order to develop the skills necessary to breastfeed²⁵. Health education is an important tool that aims to broaden the knowledge of individuals regarding their own health, especially in terms of breastfeeding. Moreover, structured and properly elaborated educational interventions contribute to increase the duration of exclusive breastfeeding⁷.

The prenatal visit is an important occasion to promote breastfeeding, and it is the professional’s duty to encourage the woman to practice it³⁷. The guidance received by pregnant women during prenatal care improves their knowledge on breastfeeding and, consequently, increases the prevalence of this social practice, especially if provided by a qualified professional³⁸. During pregnancy, the woman has enough time to assimilate the information received and clarify her doubts¹⁰.

Pearson’s correlation coefficient allowed to verify a weak correlation (r=0.05) between the mean of correct answers, in the knowledge test, and the time the women breastfed previous children (p=0.710).

A study developed in Ceará evidenced that the knowledge regarding EB was associated with the women’s prior experience in breastfeeding and the duration of breastfeeding provided to their children⁸. Despite the supposition that the previous experience in breastfeeding increases the knowledge of women on the subject, this was not the reality found by the present study. Some women breastfed their children for longer periods, even though they did not have a greater level of knowledge on breastfeeding. This fact indicates the existence of other factors, besides knowledge, which may contribute to the success and duration of breastfeeding and deserve to be studied in order to understand their relations and implications.

The authors evidenced, in this study, that postpartum women with greater knowledge on breastfeeding had studied for nine or more years, attended six or more prenatal visits and received guidance regarding breastfeeding during pregnancy.

These findings contribute to improve care and research in the health area. The identification of the aspects related with the knowledge of parturients on breastfeeding allows to propose educational programs, to reorganize health services and to implement specific and targeted actions, contributing to keep this practice.

Therefore, during the delivery of care to women in the pregnancy-puerperal cycle, nurses must take into consideration the insertion of the knowledge and practice of breastfeeding in a sociocultural context. Based on this approach, it will be possible to identify the real needs of mother and child and the aspects related with the knowledge of pregnant women and nursing mothers.

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Received: 09.05.2012
Approved: 15.12.2013