Strengthening and weakening factors for breastfeeding from the perspective of the nursing mother and her family^*

Fortalecedores y debilitadores de la lactancia bajo la óptica de la lactante y su familia

Abstract

Objective:

To describe the strengthening and weakening factors for breastfeeding.

Method:

This is a descriptive multiple case qualitative study, conducted in Curitiba, Parana, with members of 17 families with children between 6 and 12 months old, through semi-structured interview and construction of genograms, analyzed by the strategy of cross case synthesis.

Results:

28 people participated in the study. Strengthening factors for breastfeeding were: the desire to breastfeed; child with facility for breastfeeding; mother with time available to the child; previous breastfeeding experience and family history of breastfeeding; the support and encouragement to breastfeed. Weakening factors were: negative expectations; the myth of weak milk; child’s disease; maternal illness; negative experiences of the mother; the absence of family history of breastfeeding; lack of a support network.

Conclusion:

Breastfeeding is a family and social phenomenon. Therefore, practices that go beyond the mother-baby dyad are necessary. The care process should include the social and subjective dimension, strengthening the support network of nursing mothers, in order to obtain more satisfactory professional practices that promote breastfeeding.

Descriptors:
Breast Feeding; Family; Social Support; Maternal-Child Nursing

Resumen

Objetivo:

Describir los elementos fortalecedores y debilitadores de la lactancia.

Método:

Investigación con abordaje cualitativo del tipo estudio de casos múltiples con carácter descriptivo, llevado a cabo en el municipio de Curitiba, Paraná, con miembros de 17 familias compuestas de niños de 6 a 12 meses, mediante entrevista semiestructurada y construcción de genograma, analizados por la estrategia de síntesis de casos cruzados.

Resultados:

Participaron en el estudio 28 miembros. Fueron fortalecedores de la lactancia: el deseo de amamantar; niño con facilidad para mamar; madre con disponibilidad de tiempo para el niño; experiencia previa de la lactante y antecedentes familiares de lactancia; el apoyo y el incentivo para amamantar. Los debilitadores de la lactancia fueron: expectativas negativas; el mito de la leche flaca; la enfermedad del niño; las afecciones maternas; vivencias negativas de la madre; la ausencia de antecedentes familiares de lactancia; la ausencia de apoyo y soporte de la red.

Conclusión:

Amamantar es un fenómeno familiar y social, por lo que son necesarias prácticas promovedoras que extrapolen el binomio madre-bebé. En el proceso de cuidar se debe buscar la involucración de la dimensión social y subjetiva, mediante el fortalecimiento de la red de apoyo a las lactantes, a fin de lograrse prácticas profesionales más satisfactorias y promovedoras de la lactancia.

Descriptores:
Lactancia Materna; Familia; Apoyo Social; Enfermería Maternoinfantil

Resumo

Objetivo:

Descrever os elementos fortalecedores e fragilizadores da amamentação.

Método:

Pesquisa com abordagem qualitativa do tipo estudo de casos múltiplos com caráter descritivo, realizado no município de Curitiba, Paraná, com membros de 17 famílias compostas de crianças de 6 a 12 meses, por meio de entrevista semiestruturada e construção de genograma, analisados pela estratégia de síntese de casos cruzados.

Resultados:

Participaram do estudo 28 membros. Foram fortalecedores da amamentação: a vontade de amamentar; criança com facilidade para mamar; mãe com disponibilidade de tempo para a criança; experiência anterior da nutriz e antecedentes familiares de amamentação; o apoio e o incentivo para amamentar. Os fragilizadores da amamentação foram: expectativas negativas; o mito do leite fraco; a doença da criança; as afecções maternas; vivências negativas da mãe; a ausência de antecedentes familiares de amamentação; a falta de apoio e suporte da rede.

Conclusão:

Amamentar é um fenômeno familiar e social, portanto são necessárias práticas promotoras que extrapolem o binômio mãe-bebê. No processo de cuidar deve-se buscar o envolvimento da dimensão social e subjetiva, por meio do fortalecimento da rede de apoio das nutrizes, a fim de obterem-se práticas profissionais mais satisfatórias e promotoras da amamentação.

Descritores:
Aleitamento Materno; Família; Apoio Social; Enfermagem Materno-Infantil

INTRODUCTION

A recent study estimates that increasing breastfeeding worldwide could prevent 823,000 child deaths and 20,000 deaths from breast cancer among mothers every year. The growing epidemiological and biological discoveries over the last decade have increased the number of known benefits of breastfeeding for women and children⁽¹⁾. Nevertheless, low rates of breastfeeding are still reported in Brazil, where the prevalence of exclusive breastfeeding (EBF) in children under 6 months was 41% and the average duration of EBF was 54.11 days (1.8 months). This shows that more than half of Brazilian children are not on EBF until the age of 6 months⁽²⁾.

Several political and social actions with the objective of promoting breastfeeding have been developed in the country in recent decades. The first initiatives date back to 1981, when the National Breastfeeding Incentive Program (PNIAM - Programa Nacional de Incentivo ao Aleitamento Materno) was created. From then on, several advances have been observed in EBF indicators in the country⁽³⁾. However, it should be noted that the policies and strategies developed so far in Brazil for the promotion, protection and support of breastfeeding continue to incorporate restricted and fragmented conceptions of the maternal function of women in relation to breastfeeding and to explore the role of family, health professionals, society and state in a superficial manner. Successful breastfeeding is not only a woman’s decision, but a collective and social responsibility⁽⁴⁾. Incidence and duration of breastfeeding are influenced by women’s intentions, maternal and child health conditions, maternal work, family support, health professionals, cultural issues⁽⁵⁾ and even cohabiting with a partner⁽⁶⁾.

Given this scenario, research reports the need for further studies that seek to develop maternal and professional skills to maintain breastfeeding and enhance strategic actions to support women⁽⁷⁾. Research that goes beyond the biological dimension of breastfeeding, strengthening the social role, can have an impact on public breastfeeding policies. In this perspective it is necessary to ask: “How do the strengthening and weakening factors for breastfeeding work?”. In order to answer this question, the objective of this study was to describe the strengthening and weakening factors for breastfeeding.

METHOD

Type of study

This is a descriptive multiple case study with a qualitative approach, based on the methodological framework of Yin⁽⁸⁾.

Scenario

The study was conducted in the city of Curitiba, Paraná state, in 10 Health Units (HU) with Family Health Strategy (FHS). One HU was drawn per Health District, among the 10 districts of the city.

Population

Participants were 28 family members from 17 families with children aged 6 to 12 months, living in the city of Curitiba and being seen in the HU selected. The sample consisted of 17 mothers, seven fathers and four grandmothers.

Selection criteria

The following inclusion criteria were adopted: being a mother, father or family member of an infant aged 6 to 12 months, breastfeeding when discharged from the maternity ward; and family enrolled in the HU selected. Exclusion criteria were: being under 18 years old; and having difficulty communicating. The study participants were guaranteed confidentiality of information and anonymity. Acronyms were used for their identification. The study members did not know the researcher previously and were informed about the researcher's education, interest in the subject and the objectives of the study. Those who voluntarily agreed to participate signed the Informed Consent Form and were informed of the possibility of withdrawal. The sample was defined by data saturation, related to the achievement of the objective and understanding of the studied phenomenon, regardless of the number of interviews.

Data collection

Data was collected from March to April 2017 through interviews. The researchers developed semi-structured instruments for the mother, father, women and other family members. The instrument consisted of the characterization of respondents (civil status, level of education, obstetric history, prenatal care, work, income), characterization of the infant (date of birth, gestational age, place of birth, complications) and questions related to breastfeeding. The latter included pre-birth expectations, breastfeeding experience, participation of the family, reasons for maintaining or interrupting breastfeeding, people and aspects that influenced this process, and the role of health professionals.

The first interviewee in each family was the mother of the infant and then other family members who participated in breastfeeding were also interviewed. All interviews were conducted by the same researcher at the HU facilities, at the family’s home or by telephone. The interviews had a mean duration of 15 minutes and were recorded in audio and later transcribed. After transcription, interviews were returned to participants by email or Whatsapp® message, for correction and review, if necessary.

The genogram was used for the analysis of family structure and relationships, as this instrument provides graphic representation of the family through symbols, showing its characteristics, relationships and the important events experienced by the generations⁽⁹⁾. In this study, the genograms were constructed during the interviews with the mothers and were used to represent the nursing mother’s family context, in order to complement and guide the individual analysis of the reports. The nursing mother was adopted as the index person of the genogram, and symbols represented the referred family, the quality of family relationships and women of the family who had experience with breastfeeding for 6 months or more and for less than 6 months.

Analysis and processing of data

The family was considered the unit of analysis and Cross Case Synthesis and Analysis was used. By definition, this is a technique that applies to multiple case study analysis, seeking to explore whether cases replicate or contrast with each other⁽⁸⁾.

Initially, each interview was individually read and the initial codes were constructed by the researcher. A synthesis table was elaborated for each family studied and then tables were compared with each other. After that, the data was organized in the MAXqda® software to group the speeches into thematic categories and detailed analysis. It should be noted that⁽⁸⁾ word-for-word records are only part of a series of evidence of a case study, and, for a diverse set of evidence, it is necessary to develop unique analysis strategies. In this study, the construction of mental maps containing the categories was used as part of the analysis strategy. After the completion of the categories in the software, the cross-case synthesis of the study families was performed, through the elaboration of a new synthesis table with the main information obtained in data analysis. At this moment, the genogram was used to compare the data from the structural assessment of each family, observing how the stories and family antecedents of breastfeeding complemented and contrasted with one another, and relating them to the categories that emerged from the interviews.

Ethical aspects

The research followed the ethical precepts of voluntary, informed and consensual participation, with anonymity and confidentiality of participants, according to Resolution 466/2012 of the National Health Council. The project was approved by the Research Ethics Committee of the Health Sciences Department of the Universidade Federal do Paraná, protocol 1.766.141, on October 7, 2016.

RESULTS

The profile of the study participants was: mothers between 19 and 42 years old, in a stable union, with complete/incomplete secondary education, with more than three children, most did not work outside their home; fathers between 25 and 52 years, with incomplete elementary education; grandmothers between 43 and 77 years, with incomplete elementary education; and mean household income of one to two minimum wages.

The analysis of the data from the 28 interviews generated 993 codes in the software. The thematic categories that emerged from the data were: Perception of Breastfeeding (180 codes), Maternal Condition (136 codes), Child Condition (178 codes), Family Experience (159 codes) and Social Support Network (340 codes). Figure 1 presents the thematic categories of the elements that influence breastfeeding, and then presents the corpus of the analytical process:

Figure 1
Factors influencing breastfeeding.

The perception of breastfeeding was mostly characterized by positive expectations, evidenced by the desire to breastfeed. The view of family members is a strengthening factor; they see breastfeeding as necessary for the child, as it protects them from diseases and allergies, maintains health, calms them down and promotes bonding.

(...) I couldn’t wait to breastfeed again (M 4).

(...) I breastfed my children to see them beautiful, bonny, because I had a lot of milk, wow, a lot of milk (G 3).

(...) well, it is up to 6 months, so the child can gain antibodies to protect from disease (F 14).

The expectations and views of the families that weakened breastfeeding were related to lack of milk and difficulty breastfeeding. Reinforcing this discourse, myths and beliefs related to a perception of “weak milk” and questions if the milk was sustaining and being enough for the baby were revealed.

(...) I first imagined I would not have milk, I imagined that I would not be able to breastfeed her [daughter], as no one in my family could, it made me have only negative thoughts (M 13).

(...) [the mother milk] was not sustaining her, because the [baby formula] is strong, then it did not sustain her and I had to give [another baby formula] (M 12).

Regarding the condition of the child, it was shown that healthy children and those who were easy to breastfeed were more successful in breastfeeding than those who used milk formula.

(...) The baby never had difficulty breastfeeding (F 13).

(...) In the three days I was in the hospital, he only had the complement (M 12).

Excessive crying behavior was a weakening factor for breastfeeding, as well as the biological conditions of disease, prematurity and difficulty in weight gain, which had negative effects on the outcome of breastfeeding.

(...) I stopped breastfeeding and she was still crying all night (M 2).

(...) He was hospitalized, so they gave him [baby formula], then he didn’t want the breast anymore (M 8).

With regard to the Maternal Condition, the speeches showed that it was necessary to organize the routine and time of the mother for her to be able to breastfeed and that, despite working outside, some women managed to maintain breastfeeding.

(...) I worked, then they [children] stayed in the daycare center, then I would go there and breastfeed the two, put one here and the other here, and the two breastfed, no problem. (M 10).

The biological condition of maternal disease, problems with the breast during breastfeeding, either by fissures, bleeding or even the perception of insufficient milk were weakening factors.

(...) the milk dried up, I didn’t have the nipple, and then as I tried to breastfeed and couldn’t, it started to dry up, then when I went to the health unit, I no longer had [milk] (M 7).

Likewise, the emotional conditions of anxiety and stress were associated with early weaning:

(...) you go through stress and you know that stress has a lot of consequences for you, including the lack of milk, milk drying up, I know it is a bit of that (M 3).

The Family Experience with breastfeeding, identified through the analysis of the genograms (Figure 2) and interviews, showed that previous positive experience of the nursing woman breastfeeding other children was one of the aspects that strengthened breastfeeding.

(...) I breastfed my children, my older one I breastfed up to 1 year old, the second one up to almost 10 months old, he weaned himself, the third was up to 3 years and 4 months old (M 9).

The presence of family members with breastfeeding experience contributed positively to more effective and longer breastfeeding, Lack of experience, negative experiences and absence of a family history of breastfeeding contributed to difficulties in breastfeeding that led to weaning.

(...) In my family when women have a baby, I always see them breastfeed until a certain time, I have never seen them bottle feed (M 7).

(...) When he [baby] was sucking, she [wife] felt some difficulty, maybe it is for these issues that I told you about not having experience or anything, as it was the first child (F 3).

Family history of breastfeeding can be seen in the F9 family genogram (Figure 2), which shows that the mother and the sisters-in-law breastfed for 6 months or more. The analysis of this representation makes us consider that women who had breastfed in this family acted as example for the nursing mother and, also because of their close relationship, had a strengthening role in encouraging breastfeeding. Her mother-in-law did not breastfeed; however, the conflictual relationship between the two may have contributed to the fact that the mother-in-law’s experience did not influence the mother’s decision to breastfeed.

The social support network of the nursing mother and her family was identified as a strengthening factor when it provided the following functions: material support and services, such as caring for other children, helping with chores and with breastfeeding, provided especially by the father and the maternal grandmother of the child; cognitive guidance and advice, provided through the breastfeeding support offered by nurses and other health professionals; social companionship, through presence, emotional support and incentive.

(...) I told her [nursing daughter] that breast milk is the best vitamin for the child, you don’t even have to give water to the baby if it is breastfeeding (G 8).

(...) They advised there in the maternity ward (...) they explained how the baby latches on and how to put the breast in his mouth, that stuff. (M 15).

(...) my husband, he is my partner, he is my friend, you know? He has to know what’s going on. If I think something is not good, he helps me, he always helps me (M 10).

On the other hand, in some situations, the network played the role of social regulation, imposing breastfeeding practices and discouraging the nursing mother.

(...) My husband would not stop pestering me to breastfeed (...) and I couldn’t, he never understood me (...) He didn’t really encourage me, he only made it worse (M 2).

(...) I jumped from hospital to hospital, but I didn’t receive any orientation (M 13).

It is evident that the gaps in the support network, as demonstrated by the lack of support and encouragement for breastfeeding and the lack of guidance from the network, are weakening factors for breastfeeding.

Figure 2
Genogram of Family F9.

DISCUSSION

The perception of breastfeeding is based on knowledge derived from the senses and memory, and it varies according to the origin of information, social and economic conditions, culture, beliefs, emotions, skills, needs and goals⁽¹⁰⁾. A study conducted with Mexican women living in the United States of America identified that cultural background is fundamental in the decision to breastfeed⁽¹¹⁾. In this study, one found that, in general, families have a good outlook on breastfeeding, and believe it provides health, protection and bonding. However, some mothers reported that, during pregnancy, they created expectations related to inability to produce milk and to breastfeed. This made one infer that just knowing the advantages of breastfeeding does not give the woman the certainty that she will be able to breastfeed, leading one to understand that there are elements that influence breastfeeding other than just perception.

During the interviews, the perception of low milk supply and the myth of weak milk were described. Low milk supply is one of the most common complaints used to explain the use of milk formulas, and it is often related to the mother’s feeling that her milk supply is not enough to meet the child’s need⁽¹²⁾. Likewise, the myth of weak milk is related to families’ perception of the child’s hunger and crying, as if the milk was not sustaining the child⁽¹³⁾.

Regarding child feeding practices, step 6 of the Baby-Friendly Hospital Initiative (BFHI) recommends that newborns receive only breast milk for up to 6 months, and that milk formulas are offered exclusively when prescribed⁽¹⁴⁾. However, the reality today is that several pediatricians are not involved in the context of BFHI and often recommend the use of artificial milks⁽¹²⁾. Excessive crying behavior is a common cause of weaning, as it is often associated with parental stress, anxiety and maternal depression. Families with infants with excessive crying behavior are more likely to wean early due to perceptions of hunger and insufficient milk⁽¹³⁾.

The biological condition of the child is an aspect that also influences breastfeeding, since a healthy child is better able to breastfeed, while children who need special care and hospitalization may have more difficulty breastfeeding. Late onset of breastfeeding and separation of mother and infant during the stay in the Neonatal Intensive Care Unit were related to worse breastfeeding outcomes, especially when milk formulas are offered^(15-16).

For the interviewees, the organization of the mother's routine with the child was essential for maintaining breastfeeding, especially for those who worked outside. Another study pointed out the association between maternal work and early weaning and introduction of artificial milk in the child’s diet⁽⁵⁾. In contrast, this research identified nursing mothers who were able to maintain breastfeeding even while working outside; however, they still had difficulty maintaining exclusive breastfeeding. Despite of recent policies to extend the maternity leave from 4 to 6 months in Brazil⁽¹⁷⁾, it is known that this right is not guaranteed for all mothers. Many mothers interrupt EBF because they have to go back to work before 6 months, which demonstrates the fragility of maintaining exclusivity and the need to expand these public policies.

Maternal disease was listed by families as a reason for the interruption of breastfeeding, as it was related to the separation between the mother and the baby and the use of drugs contraindicated in breastfeeding. It is worth noting that, when treatment is required, the health professional should seek medication compatible with breastfeeding⁽¹⁸⁾ and enable the mother and baby to stay together during hospitalization. Nipple trauma and breastfeeding pain, cited by the research participants, are common problems in the first months after delivery, which weaken breastfeeding and may make women lose their desire to breastfeed^(19-20). Other weakening aspects are postpartum anxiety and stress, which affect lactation due to the action of hormones that affect milk production and composition, as psychological responses to stress⁽²¹⁾. Evidence suggests that anxious puerperal women are less likely to breastfeed and more likely to start offering milk formula⁽²²⁾.

Personal experience and a positive history of breastfeeding in the family, identified through the analysis of family genograms, were considered strengthening factors for the nursing mothers of this research. Research carried out in Scotland shows that a woman’s successful personal experience in breastfeeding other children contributes to making her feel safer with this practice⁽²³⁾. Knowing someone who has breastfed for more than 1 month or having been breastfed as a child are relevant factors to decrease early weaning rates^(23-25). On the other hand, in contexts where there was no family history of breastfeeding, fewer women in the family tend to breastfeed⁽²⁶⁾.

In this sense, the use of the genogram allowed identifying women who breastfed and who weaned early in the family. The use of this instrument with this approach can contribute to the work of the Family Health Strategy teams as a breastfeeding promotion tool. When identifying a family with a negative history of breastfeeding, the health professional providing prenatal care can closely monitor pregnant women and future nursing mothers, to compensate for gaps in the family and to strengthen and expand the support network. Likewise, when identifying a positive family history of breastfeeding, the professional can stimulate the participation of the family in the prenatal and postpartum period, so they can encourage the nursing mother to breastfeed.

Regarding the breastfeeding support network, it seems that one of the main influences on women’s experience regarding their child’s feeding is their family’s ability to support breastfeeding⁽²⁷⁾. Nursing women in this research recognized the important role of the partner in the division of household chores. This data corroborates other research that highlighted the activities in which nursing mothers needed help, which included household chores, caring for the baby and other children, and meal preparation⁽²⁴⁾.

The nurses were listed in this research as direct assistants of breastfeeding through massages, breast milking and guidance. Literature review reinforces that the main role of health professionals is to provide advice, guidance and information about breastfeeding, clarification of myths, encouragement of breastfeeding for the duration of 6 months, and direct help in breastfeeding⁽¹²⁾. Studies have shown that prenatal counseling was a protective factor for breastfeeding^(28-29). Even with this evidence, some families in this study experienced absence of adequate guidance at HU and in prenatal care.

There is evidence that, when initiating breastfeeding, it is important that women receive verbal support through compliments and encouragement that can stimulate her. Maternal grandmothers are referred to as key people in the breastfeeding process. Partners are seen as indispensable. A meta-synthesis has identified that mothers who breastfeed have greater social support from their network than mothers who offer milk formulas to their children⁽³⁰⁾. Reports show that the empathic presence of people can reduce the impact of stress and contribute to lower levels of anxiety, depression and physical pain⁽²⁷⁾.

When the family criticizes the woman’s decision to breastfeed, it often affects the woman’s ability to seek support from the family as well as her feelings about the family members⁽²⁸⁾. Early identification of gaps in family support may allow the establishment of other bonds in the social network, in order to compensate and allow women to find examples and support for breastfeeding⁽²³⁾. There is a need to expand the positive dimension of breastfeeding, so that families receive the support they need during this process. Therefore, it is important to strengthen practices that promote effective and long breastfeeding. There must be effective public policies implemented in health services to strengthen the social support network of nursing mothers, as breastfeeding should not be only the responsibility of this family.

Moreover, one recognizes the limitations of this study, as it was conducted in a limited region, that is, a region with its own culture and behaviors. Therefore, it is not possible to state that the circumstances presented here can be repeated or applicable in other contexts. The perspective is open for further studies of this nature, as there are researches that address the weakening factors of breastfeeding, but there is still little evidence of effective actions to strengthen breastfeeding.

CONCLUSION

The families had as strengthening factors for breastfeeding: the perception of breastfeeding as something important and necessary for the child; a healthy child, with facility for breastfeeding; mother with availability of time for the child; previous experience of the mother with the breastfeeding of other children; the family history of breastfeeding; the support and incentive to breastfeed, especially from the father and grandmother; and the support of health professionals, through guidance and support.

The weakening elements of breastfeeding were: negative expectations; the myth of weak milk; excessive crying, prematurity and hospitalizations of the child; anxiety and illness of the mother; lack of experience and negative experiences of the mother; the absence of a family history of breastfeeding; a support network with imposing attitudes; and lack of support. In the presence of these weakening elements, in addition to family support, the mother needs to receive the support of professionals and health services, with effective and empowering institutional policies, in order to be successful in breastfeeding.

The breastfeeding care process should go beyond the mother-child dyad, bringing a strengthening support network from both the family and the health professionals, especially nursing. This care should involve the subjective dimension, which includes the desire to breastfeed, the concept of breastfeeding, the woman’s experience, and the family history of breastfeeding. Special attention should be given to women and their families for the construction of the breastfeeding process, starting from the prenatal phase and considering their stories and successful experiences. Understanding the social and subjective dimensions can redirect the care process towards more satisfactory professional practices that promote breastfeeding.

In this research, the use of the genogram to contribute to the understanding of the family structure and context is considered innovative. Given that the use of this instrument focused on family history of breastfeeding is not common, it should be noted that nurses and physicians of the Family Health Strategy may benefit from using it with this focus, as it contributes to a deeper view of the family, enabling interventions targeted at the gaps found. This study may serve as a basis for the formulation of new public policies that present a broader vision, through the inclusion of the family in the entire breastfeeding process.

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• ^*
  Extracted from the dissertation: “Influências na amamentação: percepções, experiências familiares e apoio social”, Universidade Federal do Paraná, Programa de Pós-graduação em Enfermagem, 2017.

• Erratum

  On page 1, in the authors’ names:
  Where was written:
  Anna Chiesa³,¹
  Now read:
  Anna Chiesa³

Publication Dates

• Publication in this collection
  08 May 2020
• Date of issue
  2020

History

• Received
  31 July 2018
• Accepted
  13 Aug 2019