Influences of Non-Accession to Exclusive Breastfeeding : Understanding of Feminine Subjectivity

Tássia Regine de Morais Alves1, Jovanka Bittencourt Leite de Carvalho2, Rosangela Diniz Cavalcante3, Gracimary Alves Teixeira4, Flávio César Bezerra da Silva5, Andreza Maria de Oliveira6, Glauber Weder dos Santos Silva7 1 Nurse. Master student of the PostGraduation Program in Nursing, Federal University of Rio Grande do Norte/UFRN. Natal (RN), Brazil. 2 Nurse. Ph.D. in Health Science. Professor of the Post-Graduation Program in Nursing/School of Health, Federal University of Rio Grande do Norte/UFRN. Natal (RN), Brazil. 3 Nurse. PHD student of the PostGraduation Program Models of Decision and Health, Federal University of Paraíba/UFPB. Paraíba (PB), Brazil. Health School professor at the University of Rio Grande do Norte, Brazil. 4 Nurse. Doctoral student of the PostGraduation Program in Nursing, Federal University of Rio Grande do Norte/UFRN. Natal (RN), Brazil. 5 Nurse. Ph.D. in Nursing.Professor of the School of Health, Federal University of Rio Grande do Norte/UFRN. Natal(RN), Brazil. 6 Nurse. University of Rio Grande do Norte, Brazil. 7 Nurse. Nursing PhD student, Assistant Professor, Federal University of Rio Grande do Norte. Natal (RN), Brazil.


Introduction
In view of current scientific knowledge, the Breastfeeding (BF) continues to play an important role in the health of women and children, as it combats malnutrition and starvation in the early years of life.Furthermore, in many cases, it is responsible for ensuring child survival, especially in unfavorable conditions.Addition to being the best source of nutrition for children, at this stage, provides psychological and immunological benefits that optimizes healthy child development [1] The BF is included as one of the Millennium Goals among the national priorities.Moreover, it is considered the strategy that has most impact in preventing morbidity and mortality, promoting physical and mental health in infants and lactating women [2].children under six months old who are not breastfed are at high risk of not having their nutritional needs met.Thus there is an increase in child mortality by 20%.Also, they have four times more chances of deaths from respiratory diseases, presenting therefore higher rates of hospitalizations [3].
The United Nations Children's Fund (UNICEF) estimates that 50% of infant mortality under one year of age occurs in the first week of life.It emphasizes the importance of introducing breast milk soon after birth, because significantly reduces neonatal mortality at 65.6%.Moreover, if that breastfeeding continues to be offered for children up to the sixth month of life it can avoid annual 1.3 million deaths in the age group up to 5 years [1].
Although BF has been constituted historically as a resource and natural process with the main sources of nutrients for children, it is known that the occurrence / effectiveness is influenced by external factors.They can be cultural, religious, demographic and socioeconomic backgrounds; they may also be due to negative past experiences, primiparous, low education, youth and single mothers, and to certain maternal diseases and mammary complications [4].
In order to minimise these factors, the World Health Organization (WHO) and UNICEF have joined efforts to promote and support exclusive breastfeeding (EBF), so that mothers can establish and maintain this practice up to six months the child's life.However, this reality in Brazil is still far from being achieved according to data from the II Breastfeeding Exclusive Prevalence Research.Thus, on the prevalence of EBF, the Brazilian Federal District and Capital Cities showed 41.0%, while the Northeast have revealed 37.0%, representing the worst rate in the country.[5] In this context, the possibility of promoting and encouraging breastfeeding, early on, is in prenatal care.Prenatal is the right time to start guidelines for the proper technique, benefits and possible difficulties that the mother can find during lactation [6].Thus, the nurse takes vital role in regard to the BF practices, in prenatal low risk, according to the Law of Nursing Professional Practice No. 7,498 of June 25, 1986.In assuming this role, the nurse has competence to guide about the nutritional, immunological, emotional and physiological benefits for the mother-child [2].
In this perspective, there is a negative reality and indexes unsatisfactory in the city of Caicoin the State of Rio Grande do Norte, Brazil, in relation to adherence to BFE in the first months of a child's life.[7] Based on these and knowing the recognized benefits that this practice provides the following guiding questions emerged: What difficulties and determinants of non adhesion to exclusive breastfeeding?
The present article, across the introductory summarization of its problematic, aims to investigate the difficulties experienced by mothers influencing the failure of exclusive breastfeeding (EBF).

Method
This is an exploratory and descriptive study with a qualitative approach.The qualitative approach responds very specific issues, such as the universe of meanings, reasons, aspirations, beliefs, values and attitudes.[8] The survey was conducted in four areas covered by Family Health Strategy (FHS) in the city of Caico, located in the micro region of Western Seridó of Rio Grande do Norte, Brazil.This locality was chosen to present low exclusive breastfeeding rates (<50%) in the period January-April 2012, according to information of the Information Primary Care System (SIAB).
The sample consisted of 14 women attending in the four areas defined for research, through the following listed criteria for inclusion of participants: reside in urban areas coverage FHS, not be breastfeeding or not breastfeeding exclusively between the first and fourth month postpartum and have performed prenatal with nurses of municipal ESF.Exclusion criteria were under 18 years old.
The data collection was carried out from January to March 2013 through semi-structured interview recorded on electronic device (mp4) with written permission from each participant.The interviews were conducted during home visits after reading and signing the Consent and Informed.
Data from interviews were analyzed as from the content analysis (CA), in the form of thematic analysis.The use of this technique had the aim to identify the cores direction.This analysis mode lets you bring meaning to the expected object from the three complementary phases: pre-analysis, exploration of the material and processing of results, including inference and interpretations [9].
It is emphasized that this article is a clipping of the project of scientific initiation entitled Difficulties found by women regarding adhesion to exclusive breastfeeding, contemplated by funding scholarship inserted into the Institutional Scholarship for Scientific Initiation Program of Universidade Federal do Rio Grande do Norte.
Attending the ethical principles and to preserve the anonymity of the participants, during the presentation of the results It was used coding acronyms (A1, A2, A3, A17...

Results
It were identified as difficulties the experiences of mothers who influencing the failure of exclusive breastfeeding by way of example: pain; negative influences of familiar; job out of home and various household duties; insufficient information and weaknesses in communication among professionals of prenatal care; insertion of artificial teats (bottles) in the hospital.

Influences on breastfeeding
Among the mammary complications, the appearance of nipple fissures accompanied by bleeding and pain has been mentioned by mothers as the most difficult to continue breastfeeding: Oh, I had great difficulty to breastfeed.My chest has crackedit.It was injured, stiff, then after the milk stopped producting.It was quick to stop leaving the Milk.And after it has cracked it was eliminated blood.

A1.
I stopped breastfeeding because I could not stand it, it was too much pain, too much pain, so I waited undo the rigid area of the breast.After the rigid area disbanded, has dried milk, then I had no more like breastfeeding.So I did not put over the baby to breastfeed because I could not stand the pain, the two breasts were so.If my breast had not cracked and I could endure to breastfeed, I would have given to breastfeed, but I could not stand.

A2.
Given the difficulties and initial discomforts, some women may not be able to continue breastfeeding, feeling discouraged and stop breastfeeding.In addi-tion, the speech below reflects another reality in which even before mammary complications, there was will power and perseverance to breastfeeding but it was not successful: When the milk stopped being produced, when I went out not more milk kept trying, even with the problems I had in the breast and pain, because I wanted the baby to get stimulated to produce milk.But nothing worked, I tried, but nothing came, not dripping.So it was when I gave up breastfeeding.

A4.
The influence exerted by family members, friends, neighbors, mother in law and husband can influence positively or negatively to the practice of exclusive breastfeeding.In this sense, it points to the influence that the myths and beliefs have: My husband and I would not buy another milk, but when I touch on baby's tummy, I think it is empty.Also the baby suckles and becomes excited, loose breast, becomes crying, as if my milk had not satisfying him.

A3.
My mother says to me to buy milk, that I make a very thin porridge and I give it to baby.So am I going to notice that the baby will get fat.I had this encouragement from my mother, only her, she said it was good to give, to create child feeding only on the chest is complicated because sometimes the person must leave.

A5.
I believe she feel thirsty, so I gave her water.My minted said that I gave a little water to drink, but I also wanted to give, because the time is too hot.Also because I think so, she breast, has water in mother's milk, but I believe that the water in the milk is not enough.It was my choice and also of my minted.

A6.
I think my milk is weak, but people say there is no weak milk.So when I'm feeding the baby, the other breast milk was coming out, but now the milk does not come out more.

A8.
Given the above, even today, breastfeeding is permeated by myths, beliefs and socio-cultural habits generation to generation passed, strongly influenced by the context in which nursing mothers is inserted.Sometimes the familiar figure carries cultural heritage, which is supported by empirical knowledge of their ancestors and seek their wisdom, based on common sense, transmit these teachings.However, these actions often disagree to the scientific evidence.
Thus, the support professional is essential since it allows demystify socio-cultural aspects present in each maternal reality.
The commitment to the health in infants and the feeling of distress by considering maternal work and continuation of breastfeeding as incompatible practices, is revealed as one of the main obstacles and concerns about breastfeeding.Thus Woman seeks alternatives that can be evidenced in the following testimonials: I just do not breastfeed because I returned to work, it is difficult to reconcile ... if I did not work, I would give the breast to baby even when he did not want more... but I give porridge.I find it easier.

A7.
I had to take my other minor children to school, make lunch from home, organizing the house and with the surgery it was difficult.meaning I have to breastfeed twins, I was too overwhelmed.I had no help.I was the only person at home to do everything.

A9.
I am also concerned about the health of the baby and it gives me anguish but I need to go out to work out at home.

A10.
It is noteworthy that the job outside the home and women entering labor at market strengthen the scenario for the discontinuation of breastfeeding.

The influence of nurses in exclusive breastfeeding
Based on the following speech, he emphasizes the role of nurses in the promotion, protection and recovery of health, mediated by an integral and humanized care.The health professional appears both as a facilitator and motivating element for guidance during prenatal consultation regarding the maintenance of breastfeeding after birth.Because breastfeeding is a practice that provides benefits to children's health.However, weaknesses in the communication of nursing professionals in the framework of FHS, were highlighted , as shown in the following reports: The nurse said that I should always to breastfeed.He said that it was for me to breastfeed because it was good for the child and I had to breastfeed enough.He also said that I did not give up.But he did just say you need to breastfeed.But he did not explain the benefits too.I think he could talk more, explain easily for me to understand.

A11.
The nurse guided me, but let's say it was a superficial way.She did not explain in detail the benefits, but she always told me that I breastfeed because it was better and ready!The most important guidelines it was even to deal with the baby's arrival, she spoke it.She also guided me the way I take the nipple, not to hurt, that sort of thing.

A12.
Faced with the mother claims it was possible to identify the desire of mothers for more intense guidance about breastfeeding during prenatal care.It is possible to understand that the health professional did not provide justifications and the importance of exclusive breastfeeding or it occurred in a way miscommunication.This shows there is an important gap to be filled.
In this context, during the prenatal women need to acquire knowledge about breastfeeding.Especially regarding benefits, care of the breasts and breastfeeding techniques even possible complications that may arise in the course of this practice.In the meantime, they reveal they had not received clarification about possible difficulties that could arise during lactation, as follows: When I went to consultations they did not tell me that it could give rise to problems during breastfeeding.He spoke to me it was important breastfeed because it was a complete food, good for the baby, if I did not want to introduce another type of food, I could breastfeed exclusively up to six months, with only breast milk with no water, tea or any other type of food.

A13.
Deserves emphasis the trivialization of mother's feeling on the part of health professional who assists women in prenatal care, contributing to the abandonment and breastfeeding discouragement: The nurse said that it was always for me to breastfeed, but she never said that I could have these problems.According to her, even with all this suffering I still had to give the chest, but I could not stand, it was a lot of pain.But I think she was to tell me the truth, because on television, all these things is very beautiful, but should say that could present problems during breastfeeding of child, because they speak only good things. A14.

InternatIonal archIves of MedIcIne sectIon: obstetrIcs & GynecoloGy
ISSN: 1755-7682 The trivialisation of feelings experienced by mothers as from the health team was identified with frustration at the experience of an imperfect reality, full of distant difficulties, especially the idealization that media reports.In advertisements breastfeeding constitutes a generative practice of happiness, pleasure and without difficulties.Moreover, the lack of sensitivity of some health professionals front of the woman's pain with a vertical and reductionist attitude, does not allow the necessary support to women.That situation is configured as one of the discouraging breastfeeding factors.
It is noticed that the information provided to mothers were insufficient.Thus, breastfeeding is a process that requires constant learning, family support and encouragement and health professionals that assists woman.So it's not an instinctive or automatic practice.In fact breastfeeding is an action guided by subjectivity and experience of women.Moreover, it is known that the benefits of breastfeeding for women's health are few dealt during prenatal consultations.Usually the information is fully dedicated to children's health: The nurse said that I breastfeed because it was good for children's development, that with breastfeeding the child grows healthier.My Health Agent informed me about problems that could arise in breastfeeding, that breast could hurt something, but afterwards returned to normal.

A15.
The nurse told me a lot of information.That's good I breastfeed up to six months because of disease, which prevents disease, which is good for the growth of the baby, I give it only breast milk, only breastfeed until the baby be six months.

A16.
With regard to guidance and support received in the hospital setting, it is perceived inadequate practices which resulted in women psychological distress, by the introduction of artificial nipples, making it difficult to breastfeeding: At the maternity nursing my baby fed with supplement in the baby bottle.The first milk to my baby was in the baby bottle, and this baby bottle came to my room for me to feed the baby.But as I was inexperienced, I did not know which can not give, that had to be in the cup.I heard that should occur in the cup, but I did not know it would greatly hinder breastfeeding.
[...] Then vavy was drinking the milk in the baby bottle, I came home and continued to do this.When my milk came out, he did not sucked, I would put the chest and he took off.He never took the milk in the cup and even in spoon, always it happened in the bottle.It was a very serious mistake of the hospital have given milk to my son in the baby bottle, because it should have been in the cup.

A17.
Currently stands quite widespread contraindication of artificial teats through the media, in view of the interference that those cause adhesion to exclusive breastfeeding.However, misconduct of the health team are held often by staff do not know the hazards caused to the mother/child dyad and the whole family, or by professional unpreparedness.

Discussion
Breastfeeding is a complex phenomenon, not being considered a purely instinctive and biologically determined act.In fact it is a practice heavily influenced by historical, social and cultural context in which the mother is inserted [10].In addition, the socioeconomic aspects, maternal employment, marital status, income, type of delivery, inadequate guidelines during the postpartum period and pre natal, nutritional status of the mother, reasons related to the environment, maternal personality, their emotions, the relationship with the partner and family, maternal diseases and mammary complications influence this practice [11].
Exclusive breastfeeding aims to ensure the newborn quality of food, since it is a safe and economical way to feedin addition to promoting the emotional bond between mother and baby.However, many factors can influence this practice, as identified in this study, including insertion of artificial nipples in the hospital setting disregarding Step 9 of Baby Friendly Hospital Initiative (BFHI): Give no artificial teats or pacifiers to breastfed infants.In addition to the aforementioned factor this study also revealed: difficulties experienced by mothers as pain; negative influences of familiar; job out of home and the various household duties; insufficient information and weaknesses in communication among professionals of prenatal care.
Family influences, inadequate guidance, improper promotion of breastmilk substitutes and use of artificial nipples bar or hamper higher breastfeeding rates in Brazil [12].The introduction of artificial nipples reduces the frequency of feedings, leading to decrease in the production of breast milk, as well as a source of contamination and alteration in oral dynamics.This issue deserves attention in the health policies for the child population This is due not only by the frequent association towards early weaning, but also due to other negative effects on the orofacial development and its association to increased risk of infections, among other undesirable outcomes [5].
Research demonstrates that marketing practices related to breastmilk substitutes influence the conduct of health professionals and mothers regarding infant feeding.Practices prohibited by the International Code of Marketing of Breast-milk Substitutes have proved harmful to infants, since they increase the likelihood that babies be fed with infant formula or other items decreasing the practice of exclusive breastfeeding [13].
The mammary complications are also identified as one of the main causes for that exclusive breastfeeding is discontinued.The nipple trauma is most responsible for the abandonment of breastfeeding, 80-96% of mothers experienced some degree of pain and discomfort in the first week after delivery.Among the associated factors stand out primiparity, the absence of the partner, the breasts in turgid and engorged conditions, semiprotrusos and/or malformed and depigmented nipples, gripping and inadequate positioning of baby.[14] Regarding the maternal employment, misinformation about the rights and duties employment, lack of support offered by the company, family influence, lack of support from family and health professionals on issues related to breastfeeding and job contribute to the abandonment of exclusive breastfeeding [3].Face of these considerations, mothers who exercise extra occupational activity home and have little family support, present a potential risk for the abandonment of exclusive breastfeeding.
Health professionals need commitment when they perform a planning specific strategies to protect the continued breastfeeding up to 6 months of child's life.It is necessary, in addition, a wide dissemination of the guideline for the working mother who breastfeeds created by the Ministry of Health in order to provide guidance in this group.
Despite the strong desire to carry out breastfeeding, lack of support from health professionals, or more experienced people within and outside the family, can be a factor contributing to the abandonment of exclusive breastfeeding [15].In this perspective, it is essential to look at the difficulties that breastfeeding has caused and suggest alternatives that solve the weaknesses and allow continuity in the process of lactation in a pleasant way.[16] It is essential that health professionals and other stakeholders, provide guidance to pregnant women.Because if some problems faced by women during breastfeeding are not identified early and treated, may hinder or prevent breastfeeding.Due to these reasons health professionals need to actively participate in this teaching throughout the pregnancy and childbirth.This moment is important for woman to be informed about possible obstacles in the breastfeeding course.In addition it must be helped to overcome the obstacles thus contributing to the success of breastfeeding and reduce morbidity and mortality.
It is essential, moreover, that all institutions (private, conveniadas to SUS, state, philanthropic and military) need to invest in the implementation of Policies that promote practice of breastfeeding in the first hour of life, following the recommendations of BFHI.[12]

Conclusions
Faced with the objective to seek to understand the difficulties experienced by mothers who influencing the failure of exclusive breastfeeding, it was found that breastfeeding goes beyond the biological aspect.Because exclusive breastfeeding suffer various social and cultural interference given that the woman as a social being is inserted in a context permeated values which interfere directly in their attitudes.
Difficult and unpleasant aspects were experienced by women, such as mammary complications, cultural and family influence and introduction of artificial nipples.In addition, the physical and psychological fatigue, difficulty in reconciling study and/ or job with breastfeeding, idealization of the perfect lactation and without difficulties, poor hospital practices and the absence of the father figure.
In this perspective, it is believed that breastfeeding can not be considered only as an exclusive problem of women.The participation of the partner and the support of society is essential for breastfeeding fully and satisfactorily occur.Awareness among professionals is necessary, understanding that characteristics of each woman and context in which she is inserted must be taken to plan and implement appropriate intervention, based on completeness.
Although many of the mentioned factors appear to explain the causes of non-adherence to exclusive breastfeeding, it is possible to suggest other reasons that explain this fact.These reasons are linked to the environment, maternal personality, their longings, family life, cultural influences and breastfeeding meanings in different contexts.
Finally, it is suggested to carry out new studies to investigate issues involving female subjectivity and a rethinking about authoritarian discourse that sometimes shifts the blame exclusively to woman on practice or not of lactation.This practice denies the different issues surrounding the complexity of the women nowadays.
Thus, recognizing the dimensions that can hinder breastfeeding means not devalue their practice.However, this situation suggests that a new path is outlined in order to understand the difficulties experienced by women to intervene more empathic manner and directed to the specific needs of each mother.