SELF-EFFICACY AND EXCLUSIVE BREASTFEEDING MAINTENANCE IN THE FIRST MONTHS AFTER CHILDBIRTH

AUTOEFICACIA Y MANTENIMIENTO DE LA LACTANCIA MATERNA EXCLUSIVA EN LOS PRIMEROS MESES POSPARTO

ABSTRACT

Objective:

to assess breastfeeding self-efficacy and to verify exclusive breastfeeding maintenance in the first months after childbirth.

Method:

a prospective cohort study with 115 puerperal women attended at a public hospital in Parobé, Rio Grande do Sul. Data were collected from August to December 2018 using a characterization questionnaire and the Breastfeeding Self-Efficacy Scale. Exclusive breastfeeding maintenance was verified through telephone contact at 30 and 60 days postpartum. Descriptive and proportional analysis was performed.

Results:

most obtained scores compatible with high self-efficacy (91.3%). The protective factors for exclusive breastfeeding were being 27 years old or less, not having difficulties in breastfeeding in the first 24 hours, and being primigravida. There was no significant relationship between the score and exclusive breastfeeding permanence, although 27% had abandoned it in the 1^st month, and 19% in the 2^nd month.

Conclusions:

high scores show that women felt safe and capable of successfully breastfeeding. There is a need for improvement in health care in order to effectively encourage and support in order to obtain better rates of exclusive breastfeeding.

DESCRIPTORS:
Breast feeding; Self efficacy; Nursing; Health education; Postpartum period; Maternal and child health

RESUMEN

Objetivo:

evaluar la autoeficacia en la lactancia materna y verificar el mantenimiento de la lactancia materna exclusiva en los primeros meses posparto.

Método:

estudio de cohorte prospectivo con 115 madres atendidas en un hospital público de Parobé, Rio Grande do Sul. Los datos fueron recolectados de agosto a diciembre de 2018, utilizando un cuestionario de caracterización y la Escala de Autoeficacia de Lactancia Materna. El mantenimiento de la lactancia materna exclusiva se verificó mediante contacto telefónico a los 30 y 60 días posparto. Se realizó análisis descriptivo y proporcional.

Resultados:

la mayoría obtuvo puntuaciones compatibles con alta autoeficacia (91,3%). Los factores protectores para la lactancia materna exclusiva fueron 27 años o menos; no tener dificultades para amamantar en las primeras 24 horas; y ser primigrávida. No hubo relación significativa del puntaje con la permanencia de lactancia materna exclusiva, aunque 27% había abandonado en el primer mes y 19% en el segundo mes.

Conclusiones:

la prevalencia de puntuaciones altas muestra que las mujeres se sentían seguras y capaces de amamantar con éxito. Es necesario mejorar la atención de la salud con el fin de fomentar y apoyar eficazmente a fin de obtener mejores tasas de lactancia materna exclusiva.

DESCRIPTORES:
Lactancia materna; Autoeficacia; Enfermería; Educación en salud; Periodo pós-parto; Salud materno-infantil

RESUMO

Objetivo:

avaliar a autoeficácia na amamentação e verificar a manutenção do Aleitamento Materno Exclusivo nos primeiros meses pós-parto.

Método:

estudo de coorte prospectivo com 115 puérperas atendidas em um hospital público de Parobé, Rio Grande do Sul. Os dados foram coletados, de agosto a dezembro de 2018, a partir da aplicação de questionário de caracterização e da Escala de Autoeficácia na Amamentação. A manutenção do Aleitamento Materno Exclusivo foi verificada por meio de contato telefônico aos 30 e 60 dias pós-parto. Realizou-se a análise descritiva e de proporções.

Resultados:

a maioria obteve escores compatíveis com alta autoeficácia (91,3%). Os fatores de proteção ao Aleitamento Materno Exclusivo foram idade menor ou igual a 27 anos; não apresentar dificuldades em amamentar nas primeiras 24 horas; e ser primigesta. Não houve relação significativa de escore com a permanência do Aleitamento Materno Exclusivo, apesar de 27% terem abandonado no 1º mês e 19% no 2º mês.

Conclusões:

a prevalência de altos escores evidencia que as mulheres se sentiam seguras e capazes de desempenhar, com sucesso, a amamentação. Verifica-se a necessidade de melhoria na assistência à saúde de modo a incentivar e apoiar efetivamente visando obter melhores taxas de Aleitamento Materno Exclusivo.

DESCRITORES:
Aleitamento materno; Autoeficácia; Enfermagem; Educação em saúde; Período pós-parto; Saúde materno-infantil

INTRODUCTION

The World Health Organization (WHO) advises that breastfeeding (BF) should remain exclusive until a child’s six months of life and maintained as a complement until, at least, two years of age. In the exclusive period, children do not need any other type of food, since breast milk has all necessary nutrients for their growth and development, without the need for any other form of food or tea/water. Exclusive breastfeeding (EBF) provides several benefits to babies, such as protection against infections, prevention of diarrhea, decreased risk of allergies, high cholesterol, diabetes and hypertension, reduced chances of obesity. Breast milk remains an important source of nutrients until the second year of life, especially proteins, fats, and vitamins.1

BF also contributes positively to the environment’s sustainability, since weaning impacts on deforestation for creating dairy cattle and its consequent pollutants, expenses for producing lactiferous foods, production of bottles, teats, accessories, cans and their labels, materials that are often not reused. Despite all the benefits of BF, this, unfortunately, does not seem to be as instinctive as the human being, needing to be guided in its preparation and practice itself, requiring qualified health professionals.2 Even with dissemination and creation of BF incentive programs, recent studies have shown a low duration of EBF, such as the one carried out in Recife, with 310 children, which found an average total BF duration of 182 days,3 and another study carried out in João Pessoa, with 103 participants, which obtained an average of 60 days.4

For BF to be effective, women must dedicate themselves to the act and have encouragement not only by family members but also by work through access to rights provided for by law, such as 120-day maternity leave, not having their jobs and wages harmed, with an hour-long break from returning to work to breastfeed their childs until the age of six months. Moreover, there have been ministerial initiatives to improve access, coverage and quality of childcare and promotion of BF since 1991, with the creation of Baby-Friendly Hospital Initiative (BFHI).5 In 2011, the Stork Network was implemented within the scope of the Unified Health System (SUS - Sistema Único de Saúde); and, recently, the Project for Improvement and Innovation in Care and Teaching in Obstetrics and Neonatology (Apice On - Aprimoramento e Inovação no Cuidado e Ensino em Obstetrícia e Neonatologia) was created aiming at qualifying childbirth and birth assistance.6

Women’s confidence and expectation in relation to their knowledge and skills in BF thir children have an influence on the success and will determine a longer period of practice. Low confidence can also increase the risk of interrupting BF by 3.1 times when compared to women with high self-efficacy.7 BF self-efficacy is referred to as the safety and ability to be able to successfully perform the task of BF, producing a desirable result. In this regard, it is essential that puerperal women are confident and receive guidance and encouragement to do so. These guidelines are obtained from health professionals, and it is important that professionals have a theoretical basis, since incorrect, incomplete or unscientific information can contribute to early weaning.7

Thus, health professionals, including nurses, have a decisive role in reversing these data for early weaning and in promoting BF. Although professionals are favorable to BF, many women show dissatisfaction with the support they receive; they need active support, correct information and, especially, professionals who show confidence in their guidelines so that they feel confident. In order for health professionals to provide good support, they need to understand what type of support, information and interaction mothers want, need or expect from them, according to the needs of each one, thus ensuring care from pregnancy to postpartum period.2^,8 Nursing consultation in child health can also constitute an action to encourage BF, providing guidance on BF, as a way to guide and intervene in the children’s nutrition.9

In addition to health professionals’ work, in order to be successful in the BF process, it is important that institutions work with protocols that enable BF encouragament, such as early BF in delivery rooms, normal birth and rooming-in to monitor BF, thus minimizing possible barriers that may contribute to early weaning.1 Therefore, it is essential that women feel assisted in their doubts and difficulties so that they can BF more safely, in order to increase self-efficacy and make BF an act of pleasure, and not an obligation.

During practical work in the region’s health services where the study took place, it was found that the difficulties in maintaining BF were related to knowledge and guidance that women had or received during prenatal (PC) and post-natal care and in their life experiences. From this perspective, this theme became interesting, considering that data on EBF prevalence in the Vale do Paranhana region, in the state of Rio Grande do Sul, were not found in the literature. The empirical knowledge indicates that hospitals guidelines cover the doubts that puerperal women present during hospitalization, and not all municipalities carry out a PC consultation between doctor and nurse. This study aimed to assess BF self-efficacy and to verify EBF maintenance in the first months after childbirth.

METHOD

This is a prospective cohort study developed in a public hospital, located in the city of Parobé, Rio Grande do Sul, which is a reference in obstetric care for several cities in the region. This municipality is the second largest in Vale do Paranhana and has an estimated population of 56,277 inhabitants.

The research was carried out with puerperal women hospitalized in rooming-in of the referred hospital. The sample calculation was made with information about the total number of 1,231 births in a hospital referred to in the previous year, 2017, considering a tolerable sample error of 7%, a confidence level of 95% and an expected loss of 10%. The sample consisted of 115 puerperal women, selected by convenience.

Women with at least 24 hours postpartum, who had already breastfed and who wanted to breastfeed exclusively have been included. It was decided to determine a minimum time of 24 hours after delivery, understanding that by that time mothers would have had contact with the BF technique, thus allowing them to answer the scale’s questions. The scale can be used at the beginning of BF,10 in order to identify possible weaknesses in order to intervene as early as possible. Children under 18 and women who were unable to breastfeed due to health or baby restrictions have been excluded.

Data collection was carried out from December 2017 to February 2018. First contact occurred between August and October, in rooming-in, with an approach in the bed itself during their hospitalization period, respecting their privacy. The instrument used contained: Part 1 - questionnaire for puerperal women characterization that integrates sociodemographic data, obstetric history, current pregnancy data, childbirth and puerperium; Part 2 - Breastfeeding Self-Efficacy Scale - reduced version.

The Breastfeeding Self-Efficacy Scale, reduced form, was validated in Brazil in 2008, from the original instrument called Breastfeeding Self-Efficacy Scale - Short Form (BSES - SF). This scale is intended to assess women’s perspectives on BF self-efficacy,11 i.e., it helps to recognize women with potential to succeed in BF as well as to point out those who need intervention. When applied during the hospitalization period, it contributes to the presence of any difficulties, which can be resolved before hospital discharge.12

The scale consists of 14 items, organized into two categories of domains: technical (8 items) and interpersonal thoughts (6 items). In the first, BF’s technical aspects stand out, such as comfort during the act; in the second, issues such as desire and motivation to breastfeed are highlighted.11 A score is assigned to each item according to the degree of agreement (1 - strongly disagree, 2 - disagree, 3 - sometimes agree, 4 - agree and 5 - strongly agree), reaching a score of 14 to 70 points. Women with higher scores have greater confidence and potential to maintain BF.11 For analysis, all scores were classified as low efficacy (14 to 32 points), medium efficacy (33 to 51 points) and high efficacy (52 to 70 points).12

The second and third contacts with participants took place between September and December, in order to follow and monitor continuity of EBF and possible difficulties in maintaining it until the second month of babies’ lives. This approach occurred through telephone contact (once a month), being guided by a script of 5 closed and open-ended questions about EB maintenance, difficulties, support network and information received about BF. When possible and if authorized by participants, an instant messaging application (such as WhatsApp) was used to schedule the best time for calls. Those participants with whom contact was not obtained after three attempts were considered to be lost to follow-up in the study.

Data were entered into the Excel program, analyzed in Statistical Package for the Social Sciences, version 21.0, and described in absolute and relative frequency. For analysis of proportions, Pearson’s chi-square test or Fisher’s exact test was used, seeking to identify the variables (sociodemographic, obstetric and BF) that could be associated with BF self-efficacy and EBF maintenance in the first months after childbirth. The assumed level of significance for tests was 5%. The scale components’ internal consistency was assessed using Cronbach’s Alpha (α=0.85), a value close to another study (0.74),11 thus confirming the instrument’s adequacy.

Bioethical aspects in research with human beings were respected, according to Resolution 466/2012 of the Brazilian National Health Council (Conselho Nacional de Saúde). Participants signed the Informed Consent Form, in two copies, one being retained by the participant and the other by the researcher. The research project was approved by a Research Ethics Committee in August 2018.

RESULTS

Mothers’ sociodemographic profile can be described as to age, in which 58.3% (n=67) were up to 27 years old, with an average age of 27.02 years (standard deviation of 6.62); 43.5% (n=50) came from the municipality of Parobé, 29.6% (n=34) from the municipality of Igrejinha and the others from other 5 municipalities in the region; the majority lived with a husband or partner (n=101; 87%), had incomplete elementary education (n=32; 27%) and average monthly income between 1 and 2 minimum wages (60.9%, n=70).

Regarding mothers’ obstetric characteristics, 73% (n=84) were multiparous; 65.2% (n=75) were able to breastfeed their previous children, with 44.3% (n=51) BF for more than 6 months; 59.1% (n=68) did not plan their pregnancy; 93% (n=107) performed more than 6 prenatal consultations for the current delivery, with consultations prevailing only with PC (n=61; 53%), followed by consultations interspersed with obstetricians and nurses (n=36; 31.3%); 90.4% (n=104) underwent PC in the public network; 56.5% (n=65) had cesarean delivery; 10.4% (n=12) had high-risk pregnancies, justified by “high blood pressure during pregnancy” (n=5), followed by “risk of miscarriage” (n=3).

All issues related to BF during the current delivery are shown in Table 1. It is noteworthy that among participants who received guidance during PC, this was mostly obtained from nurses (n=23; 50%), followed by the obstetrician (n=12; 26%). Among the information provided, “BF benefits for mother and baby” (n=42; 91.3%), “correct latch on to the breast” (n=38; 82.6%), “Mother-baby bond” (n=32; 69.5%), “not using water and teas” (n=32; 69.5%) and “preventing nipple cracks” (n=25; 54, 3%).

With regard to the difficulties in BF at immediate puerperium, it is evident the “difficulty of newborns (NB) in latching on to the breast” (n=21; 68%), followed by the complaint of “delay in lowering the milk” (n=8; 26%). As for guidelines on BF during the hospitalization period, most were offered by nursing technicians (n=39; 54%), followed by nurses (n=29; 40%).

Table 1 -
Variables related to breastfeeding by puerperal women in the current pregnancy. Vale do Paranhana, RS, Brazil, 2018. (n=115)

Variables	n	%
Received guidance on breastfeeding during prenatal care
No	69	60.0
Yes	46	40.0
Participated in groups of pregnant women
No	91	79.1
Yes	24	20.9
Time after delivery that you breastfed for the first time
Less than 1 hour	45	39.1
After 1 hour	36	31.3
More than 2 hours	34	29.6
1st breastfeeding location
Delivery room/obstetric care center	84	73.0
Rooming-in	25	21.7
Nursery	5	4.3
E/G room	1	1.0
Difficulties in breastfeeding a child in the immediate postpartum period
No	84	73.0
Yes	31	27.0
Received guidance on breastfeeding during hospitalization
No	43	37.4
Yes	72	62.6
Intend to breastfeed exclusively for how long
Up to 6 months of age or less	101	87.8
More than 6 months of life	14	12.2
Feels supported and encouraged to breastfeed
No	2	1.7
Yes	113	98.3

The scores obtained using the Breastfeeding Self-Efficacy Scale are described in Table 2, with scores consistent with high BF self-efficacy.

Table 2 -
Scores obtained by puerperal women in applying the Breastfeeding Self-Efficacy Scale. Vale do Paranhana, RS, Brazil, 2018. (n=115)

Self-efficacy scores	n	%	Mean (SD)	Median (Q1-Q3)
Low (14 to 32)	-	-
Medium (33 to 51)	10	8.7
High (52 to 70)	105	91.3
Total	115	100	59.48(6.54)	60(55-65)

There was a statistical association with high BF self-efficacy (Table 3) with age up to 27 years, having no difficulties in BF in the period up to 48 hours postpartum and being primiparous.

Table 3 -
Distribution of sociodemographic and obstetric variables according to medium and high self-efficacy for breastfeeding. Vale do Paranhana, RS, Brazil, 2018. (n=115)

Variables	Breastfeeding self-efficacy
	Medium (n=10)		High (n=105)		p*
	N	%	N	%
Age					0.044
Up to 27 years	9	7.8	58	50.4
More than 27 years	1	0.9	47	40.9
Number of pregnancies					0.023
1	4	3.5	80	69.6
2 or more	6	5.2	25	21.7
Had difficulties in breastfeeding in the immediate postpartum period					0.023
No	4	3.5	80	69.6
Yes	6	5.2	25	21.7

• *Fisher’s exact test

Follow-up to check EBF maintenance in the first two months of life is described in Figure 1. In the first month, 98 participants (85% of 115 women) were contacted and in 17 cases it was not possible to contact them, being considered follow-up loss (15 %). Of these 98 participants, 83 continued to breastfeed, 72 (73%) of them with EBF and 11 (11%) provided complementary BF, and 15 (15%) were no longer BF. In the second month, 74 participants (77%) were contacted, excluding those who had already stopped BF in the first contact (n=15), and in 9 cases contact was not possible, being considered follow-up loss (10%). Of these 74 participants, 70 continued to breastfeed, 60 (81%) of whom with EBF, and 10 (13.5%) provided complementary BF, and 4 were no longer BF (5%).

Figure 1 -
Follow-up description to verify EBF maintenance in the first two months after childbirth. Vale do Paranhana, RS, Brazil, 2018. (n=115)

Table 4 shows the variables related to EBF maintenance after two months after childbirth, considering self-efficacy scores.

Table 4 -
Variables related to EBF maintenance in the first and second months after childbirth, considering self-efficacy scores. Vale do Paranhana, RS, Brazil, 2018. (n=115)

Variables	1st month			2nd month
	Medium (n=8)	High (n=90)	Total (n=98)	Medium (n=4)	High (n=70)	Total (n=74)
	n (%)	n(%)	n(%)	n(%)	n(%)	n(%)
EBF maintenance
No	3(37.5)	23(26)	26(27)	0(0)	14(20)	14(19)
Yes	5(62.5)	67(74)	72(73)	4(100)	56(80)	60(81)
Had to offer another milk at some point
No	5(62.5)	60(67)	65(66)	3(75)	54(77)	57(77)
Yes	3(37.5)	30(33)	33(34)	1(25)	16(23)	17(23)
Had difficulty breastfeeding
No	6 (75)	55(61)	61(62)	3(75)	61(82)	64(86)
Yes	2(25)	35(39)	37(38)	1(25)	9(18)	10(14)
Received information on breastfeeding after hospital discharge
No	5(62.5)	39(43)	44(45)	3(75)	52(74)	55(74)
Yes	3(37.5)	51(57)	54(55)	1(25)	18(26)	19(26)

Of the 15 women who ceased BF on the first contact, 7 had already reported difficulties in BF in the immediate postpartum period, the main reason being the difficulty in correctly holding a newborn. The other 8 women reported difficulties after hospital discharge, also with regard to correct latch on, belief in little milk and low weight gain for their babies. Of the 26 women who reported that they were no longer in BF at first contact, 4 were discharged with the guidance of offering milk formula and had difficulties in BF during the hospitalization period, the other 22 offered another milk after discharge.

Among the puerperal women who were on complementary BF at first contact (n=11), one offered breast milk, water and teas, others complemented with milk formula. Of the 33 women who at some point offered their babies another type of milk, 7 were able to remain in EBF afterwards. The prevalent justification for this offer was to believe that they had little milk (n=14; 42.4%), followed by a baby with difficulty in drinking it (n=6; 18%) and fissure/mastitis (n=4; 12%).

Among the 37 participants who reported difficulties in BF after hospital discharge, the same situations predominantly emerged: believing that they have little milk (n=12; 32%); newborns with difficulty in grasping (n=11; 30%); and fissure (n=9; 24%). Among these, 57% (n=21) mentioned having sought help in the face of BF difficulties, with the support, mainly, of pediatricians (n=7; 33%) and obstetricians (n=6; 28.5%). It is noteworthy that some BF consultant (n=2; 9.5%) and the internet (n=3; 14%) also emerged as an information source. Of these 37 women, 8 continued to have difficulties BF at 2^nd contact and 2 started to report difficulties.

Among the participants (n=54; 55%) who reported having received information on BF after hospital discharge in the first contact, the professional who provided it was the pediatrician in 72% (n=39) and nurses in 13% (n=7). The main information received was about the benefits of BF for baby and mother (n=41; 76%), correct latch on to the breast (n=15; 28%) and BF frequency and time (n=12; 22%).

There was a significant association between being from a municipality other than Parobé with having received guidance on BF in PC (p <0.000), and being from Igrejinha was a protective factor for having received these guidelines (p <0.000). Being from other municipalities than Parobé obtained significance with the participation in groups of pregnant women during PC (p <0.012).

DISCUSSION

The results showed a prevalence (91.3%) of high self-efficacy. These results corroborate with the studies carried out in São Paulo (54.58%),12 Santa Maria (81%)13 and Teresina (95%),14 which also had a high prevalence.

Despite the high self-efficacy scores for BF found in the present study and EBF maintenance in the first months, low education level prevalence among women was evident. It is noteworthy that these women had potential to remain BF, since most (86%, n=64) did not have difficulties in BF. However, a study indicates that BF length is positively influenced by the mother’s higher level of education, especially in developed countries,15 with low education being a risk factor for early weaning.16

Regarding the data that indicate EBF maintenance in the two months after childbirth, a study developed in São Paulo with 100 puerperal women obtained results of permanence of EBF in the 1^st month of 84%, 15% complemented and 1% artificial; and in the second month, 79% of EBF, 15% complemented and 6% artificial.12

Even though 59.1% of participants in this study did not plan their pregnancy, the majority obtained high self-efficacy scores. A study carried out in Ceará indicates that pregnancy planning influences the commitment to BF and, consequently, a high self-efficacy score.7

As for PC performance, most had more than 6 consultations, meeting the Ministry of Health recommendations. A study carried out in João Pessoa showed that having less than 6 consultations has a negative effect on BF time.4

Despite this, most respondents reported not having received guidance on BF during this period, showing that professionals need to be more effectively involved in promoting BF. A study carried out in Piauí brings the importance of PC guidelines and of nurses’ performance in this assistance, being ahead in 56.2% of the guidelines,8 diverging from the present study, which resulted in only 31.3%.

Although the number of cesarean sections has not shown a significant relationship with BF self-efficacy, even though WHO recommends an ideal rate of 15%, it is important that this aspect is also reviewed and worked on in care, since a study proves the relationship between the type of delivery and BF time, and women who delivered vaginally had longer BF when compared to those who underwent cesarean delivery.17 Moreover, the rate of cesarean deliveries can be considered as an adverse factor to the continuity of EBF, being present in 15% of cases of early weaning in this research.

BF in the first hour after childbirth was still reported as little practiced in the present study, denoting the importance of being reinforced in assistance, especially if you consider a reference health establishment in obstetric care, despite not being a hospital accredited as BFHI. A study carried out in Recife, with 320 mothers and newborns, highlights the relationship of BF in the first hour of life with a high rate of maintaining BF, a practice of great incentive in hospitals accredited as BFHI.18

As for the time they intend to exclusively breastfeed, the period of less than 6 months of their babies’ lives was justified by the fact that they had to return to work. On the other hand, affirmation of a period of more than 6 months of a baby’s life evidences lack of knowledge and guidance about EBF during PC. Corroborating these data, a study indicates association between returning to work and interrupting BF before their child’s 6 months of age,19 showing a possible discrepancy between the current legislation regarding maternity leave and the one recommended by the Ministry of Health.

The need to implement strategies that allow women greater access to information on BF is evidenced by the fact that 60% did not receive information on BF during PC. Although no statistical association was found between self-efficacy and EBF maintenance, the importance of monitoring health professionals, especially nurses, to nursing mothers is highlighted, guiding and clarifying doubts related to BF, aiming to influence women’s confidence in BF.7

Another fact that shows the failure in the guidelines on BF is the minority of women who participated in groups of pregnant women during the PC. The importance of this type of educational activities like this is justified by the possibility of exchanging experiences, expectations and doubts among pregnant women about the advantages and difficulties of BF, providing overcoming possible adversities.7 It is noteworthy that the study scenario hospital offers this activity every six months, being open to participation by all women who have this service as an obstetric reference. However, like the study carried out in São Paulo,20 highlights the need to consider that this group work is also offered by the Primary Health Care (PHC) services, being an appropriate strategy for educational health promotion actions in PC and puerperium due to the advantage of reaching a larger number of women at low cost. In this regard, the need to municipalize this offer in the region of the present study is evident, thus realizing the principles of integrality and accessibility recommended in SUS.

Comparing the municipalities with the largest number of participants, it can be observed that not being from Parobé was related to having received guidance in the PC on BF, as well as being from Igrejinha was a protective factor for having this type of guidance. It can be inferred that this fact occurs through the monitoring of PC and puerperium, in the latter municipality, it occurs with the presence of a nurse, highlighting the importance of this professional being inserted in the PC team, mainly as a provider of guidelines, for successful BF.2

There was no evidence of the self-efficacy score influence presented by the puerperal women with the permanence of EBF during the maintenance period, corroborating with another study carried out in São Paulo.12 A study carried out in the Southern Region of Brazil indicated that the high self-efficacy score was a protective factor for BF.14 Low level of self-efficacy is associated with a higher risk of interrupting BF, with self-efficacy being a motivating component in adopting and changing behavior with a view to BF effectiveness and maintenance.21

It is observed in the present study that the reported difficulties to breastfeed after hospital discharge are related to lack of knowledge on BF and insecurity of puerperal women to deal with such difficulties. This situation was also observed in another study22 that identified the same factors as a cause of early weaning.

The fact that the participants who reported obstacles to BF after hospital discharge did not seek help/support from trained professionals, justifying the delay in scheduling appointments in Primary Health Care (PHC), shows the imperative need for follow-up to the puerperium and from the active search of these patients for consultations with obstetricians and pediatricians with a view to maintaining EBF. Educational actions advocating the importance of BF should be emphasized more effectively by health professionals at all levels of care.1

It was evident that those women who have high self-efficacy tend not to have difficulties in BF in the immediate puerperium. It is assumed that the immediate puerperium is decisive for the success of BF12 and that the scale provides us with information about the confidence of these women to breastfeed. Thus, this relationship shows that the instrument is a great way to assess those pregnant women/mothers who need more attention and guidance so that they can successfully breastfeed exclusively.

In this study, being up to 27 years old and being a primigravida demonstrated a predisposition to high BF self-efficacy, since they are not influenced by previous experiences. On the other hand, a study carried out in the interior of São Paulo relates the average duration of BF with the birth order, with the firstborn receiving BF for a shorter time.23

In the literature, there are controversial records about which maternal age would be a factor related to high self-efficacy and, consequently, to the longer duration of EBF. Studies indicate that being over 30 years of age proved to be a protective factor for EBF, showing that younger mothers (adolescents) have more difficulty in BF and stay for less time.21^-22 However, the observed result highlights that education regarding BF care must be reinforced among younger women, with the aim of improving BF practices.22 Furthermore, the need for health professionals to act in order to promote comprehensive, broad and contextualized care is highlighted,24 addressing aspects related to the care of mothers and babies during BF.

Follow-up loss by some participants can be presented as a limitation, typical of studies that use this method. It is considered that the reality of other places/institutions in the region may be constituted differently. There is a need for further studies to contribute with a wider scope in facing the difficulties encountered in maintaining EBF in order to qualify the assistance provided by professionals, thus signaling greater support for BF. In this context, it is suggested that similar studies be carried out in other hospitals with a longer follow-up period for maintaining BF, including those accredited to BFHI, which are committed to respecting the ten steps to encourage BF.

CONCLUSION

From the results, it was possible to observe that most puerperal women obtained scores compatible with high self-efficacy, determining that they felt safe and capable of successfully performing BF. In contrast, EBF maintenance at 30 days postpartum was relatively low compared to the self-efficacy level’s result. As factors related to high self-efficacy, age less than or equal to 27 years was evidenced, did not present difficulties in BF in the first 24 hours postpartum and be primiparous. There was no significant relationship between the self-efficacy score and the permanence in EBF in the first postpartum months, despite the fact that 27% dropped out in the first month and 19% in the second month.

The results found in this study contribute to the research, teaching and care triad, bringing data about BF, since there are no studies in the region. In addition to highlighting the need for improvements in care, with regard to BF guidelines, PC and puerperal care by the health team and, in particular, nursing aimed at promoting, supporting and protecting BF.

The aim is to contribute to nursing care for this public in order to improve EBF rates and, especially, to encourage nursing academics, professors and professionals to reflect on their role in face of this demand. Therefore, we seek to encourage constructing new health repertoires and practices that seek to support and guide women about BF.

REFERENCES

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NOTES

• ORIGIN OF THE ARTICLE

  Article extracted from the thesis - Autoeficácia na amamentação e manutenção do aleitamento materno exclusivo nos primeiros meses de vida, presented to the Nursing Course at Faculdades Integradas de Taquara, in 2018.

• APPROVAL OF ETHICS COMMITTEE IN RESEARCH

  Approved by the Ethics Committee in Research with Human Beings of the Faculdades Integradas de Taquara, under Opinion 2,840,604/2018 and Certificate of Presentation for Ethical Consideration (CAAE) 93846218.4.0000.8135.

Publication Dates

• Publication in this collection
  22 Jan 2021
• Date of issue
  2020

History

• Received
  20 May 2019
• Accepted
  10 Dec 2019