Nurses Participation in Promoting Breastfeeding

Results: Mothers are aware of the importance of breastfeeding in meeting the child's needs and favoring the affective link between them; However, it was seen that the baby weaning occurred before the pediatric recommendation period; in relation to the nurse's role in promoting the PM noted that mothers received some form of guidance on breastfeeding, indicating that it is not the lack of access to information hinders the adoption of appropriate practices AM.


Introduction
Breastfeeding is referenced in the literature as the best food for the baby and one of the most efficient ways to provide nutritional, im-munological and psychological components to the child, keeping him away from diseases and infections, in addition to establishing the mother-baby bond.
Brazil is still far from fulfilling the recommendation of the World Health Organization (WHO) on exclusive breastfeeding until the sixth month of life, and continued breastfeeding through the second year of life or more, bearing in mind that although most women initiate breastfeeding, more than half of children is no longer in exclusive breastfeeding in the first month of life [1].
According to the National Survey on Demography and Health -PNDS, held in 1996, exclusive breastfeeding reduces very quickly before the baby complete 6 months of age.It was found that about 60% of children under two months of life are fed exclusively with breast milk, and that more than 95% of them are breastfed with or without food supplement.Before the seventh month of life, that is, at 6 months, 13% of infants are fed exclusively with breast milk and other 51% are breastfed while receiving other foods [2].
The actions of encouragement, promotion and support of breastfeeding should take place in all professionals' actions, especially of nurses during the prenatal, antepartum, birth and return to puerperal consultation, in order to achieve multidisciplinary teams committed to maternal and child health [1].
The nurse is the professional who most relates with the woman throughout the pregnancy and puerperal cycle, and he/she has an important role in health education programs throughout prenatal care.In this way, the nurse can prepare the expectant mother, giving her easily and smoothly guidelines, and making her able to develop her selfknowledge, breaking the existing taboos.Nurses' assistance is crucial for the beginning, maintenance and success of breastfeeding.
The present study it has the general objective to contribute to scientific research on how nurses act to protect, promote and support breastfeeding, thus avoiding the mothers to abandon breastfeeding, or to do not breastfeed exclusively for the first six months of child's life.
Considering this problem, the following questions arose: What is the importance of breastfeeding for the child's development?What are the conduct adopted by the nurses in the care of women during pregnancy and puerperal period?What are the practices that contribute to the promotion of breastfeeding?And what else hinders this process?
Considering the scarce research regarding the nurse's posture on participation and success of breastfeeding, we aimed to analyze the nursing practices in promoting breastfeeding during pregnancy and childbirth.To this end, the following specific objectives were formulated: To identify the knowledge of lactating mothers about breastfeeding; To know the procedures adopted by nursing mothers during breastfeeding; To compare breastfeeding behaviors adopted by breastfeeding mothers with the recommendations of the scientific literature and to understand the role of nursing professionals in the adoption of breastfeeding practices.

Method
This study follows a quantitative and descriptive design, in light of the research objectives and the theoretical approach held, since it investigates the population characteristics of the investigated phenomenon and the establishment of relationships between variables from the objective measurement and the quantification of the results using data analysis statistical instrumental.The research was developed in the Family Health Strategy of the municipality of Diamante-PB [3][4].The population consisted of 50 patients registered in that unit, and who had children with the minimum age of 03 months and maximum age of 24 months.They agreed to participate in the research after the objectives clarification and after signing the Terms of Consent.
The project was approved on the basis of Resolution 466/12 which regulates the ethics of human research, through the Ethics Committee of the Integrated Faculties of Patos, under protocol number: 1.002.258[5].
Data were collected in the months of February and March 2016 through a demographic survey questionnaire and information about breastfeeding.This instrument sought to raise personal characterization data.Personal identification elements referred to: age of mother and child, education, gainful activity and marital status.The application lasted on average 15 minutes.
From the adopted objectives, data were analyzed quantitatively, using descriptive statistics.To perform the statistical analysis, data were coded and analyzed using the Predictive Analytics Software (PASW, 18).The quantitative design was started with the descriptive analysis of the participants' responses to the questionnaire of information on breastfeeding.
The presentation of the results were in the tables, graphs presented frequencies, means and standard deviations of the responses from the questionnaire.

Results
The description of the results will be presented by order of the objectives previously formulated for this study.For each objective presented, further analysis and discussion of the data will be performed in the light of the theories that guided the scientific work.Because of this, first we describe the results of the descriptive analysis performed from the socio-demographic data, then the information obtained in breastfeeding questionnaire, and finally, the analysis of the role of nursing professionals in the adoption of breastfeeding practices.
The socio-demographic data of Table 1 have revealed that, regarding the age of the participants, it was possible to note a heterogeneous profile, as this varied from 18 to 42 years old (m = 26.84;dp = 5.84).Regarding the age of the children, the average obtained was 8.54 months, and standard deviation of 3.86.As regards the marital status of participants, 90% (n = 45) were married and only 10% (n = 5) were single, none of the interviewed were widowed or divorced, as noted in Table 1.Thus, it is clear that only a small content of the sample is made up of single mothers.
In relation to the sample's education characteristics, the majority of respondents, 62% (n = 31), have completed high school, and only 12% (n = 6) have completed higher education.The degree of education presented by the participants leads to the conclusion that we are facing a sample in which the large majority concluded the formal education, and that presumably have the written code domain and possibility of access to information.
As for the employment situation, a little more than half of mothers, 54% (n = 27), were housewives, 16% (n = 8) were employees of private enterprise, 12% (n = 6) were public servers, 8% (n = 4) were autonomous, 6% (n = 3) farmers and 4% (n = 2) were students.This data inform that most mothers are exclusively dedicated to home care and children, which constitutes a favorable factor for the maintenance of breastfeeding.
As regards the advantages of breastfeeding the child, according to the research data shown in Table 2, the item referring to favor the mother and child bond had the highest percentage, with 98% (n = 49); followed by the statement that breast milk is the most suitable food their needs, with 96% (n = 48), and the item that deals with the prevention of risk of some infections, with 94% (n = 48).In turn, the "protective factor for obesity" and "prevents the risk of some allergies" items had the lowest percentage of positive responses with a percentage of 70% (n = 35) and 80% (n = 40), respectively.
From the results of Table 3, we observed that regarding the reasons that lead to early discontinuation of breastfeeding, the item that received the highest percentage of positive responses was the return of the mother to work, with 60% (n = 30).Further, the item with the highest index was dealing with the mother's idea to think that she has little milk, with 46% (n = 23) of women.These data indicate that mothers perceive the return to work as the factor that prevents or hinders the further maintenance of breastfeeding.
The lower rates of positive responses were found in relation to the fact that the baby cry a lot, with 20% (n = 10).This result suggests that the early interruption of breastfeeding has little probability of occurring in cases when the baby cries a lot.In considering the item referred to problems with the breasts, we observed a score of 34% (n = 17), which also reached low percentage values for early cessation of breastfeeding.It is clear, therefore, that the problems related to the breasts do not interfere in the availability of mothers in continuing breastfeeding.
For analysis and description of the measures adopted by mothers in breastfeeding, a descriptive analysis of the participants' responses was used to the questionnaire information on breastfeeding.This procedure made it possible to find out information about weaning, introduction to artificial milk, exclusive feeding and supplementary feeding.Notice below the descriptive data.
By analyzing at what age (in months) occurred the baby weaning in Table 4, where applicable (28%, n = 14), total responses obtained average of 5.57 months (dp = 3.21), with middle range of responses between 2.36 and 8.78, indicating that the baby weaning occurred before the pediatric recommendation period.
Regarding the analysis of the introduction of artificial milk in baby food, 54% (n = 27) of mothers stated that they made use of some kind of artificial milk in the baby food menu.The introduction of supplementary foods occurred on average to 5.56 months (dp = 1.23).With regard to exclusive feeding, the average was 3.14 months (dp = 2.35).Only 28% of the participants claimed that the exclusive breastfeeding took place until the 6 (six) months of age, as it can be seen in Figure 1.
For analysis of the nurses' role in breastfeeding promotion practices, the responses obtained were analyzed from the breastfeeding questionnaire, regarding the professional reporting them on breastfeeding during pregnancy and after the child birth.
In considering whether the mother received information about breastfeeding during pregnancy, it was noted in Figure 2 that the vast majority, 84% (n = 42) of them, received some counseling on breastfeeding, indicating that it is not the lack of access to information that makes it difficult to adopt appropriate breastfeeding practices.The question is whether the information content passed on advice to pregnant women meets the recommendations listed in the literature on the addressed subject, as this detail was not subject to analysis in this study.
Regarding the professionals analysis, in Table 5 was detected that 72% (n = 36) of surveyed mothers    obtained information on breastfeeding practices with the nursing staff.This information shows the importance of the nurse, and alerts to the need for this professional to have proper knowledge and preparation to meet pregnant women and mothers in breastfeeding.On investigating whether the mother remained breastfeeding a child under the age of two years, it was found that 72% (n = 36) of mothers were breastfeeding, while 28% (n = 14) stopped breastfeeding, as it can be seen in Figure 3.
In questioning them about who indicated the introduction of artificial milk in baby food, Table 6 shows that 80% (n = 40) of the participants stated that the decision was based on their own initiative.

Discussion
The survey of the sample's sociodemographic characteristics reveals that 90% of women are married.In turn, the marital environment experienced by most participants can be significantly able to propitiate the affective and motivational support that mothers need to initiate and continue breastfeeding.The literature states that women more likely to wean early are those who are in an indefinite marital status.Being a single mother is a condition that can interfere with child breastfeeding in an exclusive way, by the accumulation of household tasks and baby care, and especially because of the lack of psychological and social help for the role of nurturer [6].
The schooling of the interviewees had a higher percentage for those who attended completed high school, being 62% of women.In turn, some studies show weaning earlier situations in group of mothers with incomplete primary or secondary education.Women with only elementary or high school show greater possibility of breastfeeding interruption before the first four months of child's life.Mothers with higher education maintain breastfeeding for longer time, probably due to the possibility of a greater knowledge and for having more access to information about the benefits of breastfeeding, and suffering less outside influence, renouncing practices, scientifically proven, that debase the occurrence of breastfeeding [6].
Most study participants had as sole occupation the household tasks, which in a certain way is a good thing for breastfeeding maintenance.Studies have shown that mothers who work exert negative influence on the practice of breastfeeding, because mothers who reported working in companies had more chances of early weaning.It is also known that after mother getting out of home space, that is, taking professional spaces in the labor market, whether public or private, the practice of breastfeeding decreased significantly, changing breastfeeding by artificial milk, which cannot be compared to the nutrients that are present in breast milk [7].
Considering the items that showed a higher rate of positive responses in Table 2, on the advantages of breastfeeding for the baby and the mother, it is noted that mothers are aware of the importance of breastfeeding in meeting the child's needs  and in favor of the emotional bond between them.Breastfeeding is the most comprehensive food for the children during their first six months of life, since its composition is balanced and rich, containing all the nutrients needed for their development and growth.Breast milk is always at the correct temperature, promotes bonding of mother and child, prevents infant mortality, malnutrition, respiratory infections, diarrhea, orofacial myofunctional disorders, and reduces the risk of high cholesterol, allergies, diabetes, hypertension and obesity [8].
Regarding the reasons that lead to early discontinuation of breastfeeding in Table 3, the item that received the highest percentage of positive responses was the return of the mother to work, with 60% (n = 30).According to the Promoting Breastfeeding Album television series published by the Ministry of Health in 2010, mother's work does not represent a barrier only if it provides favorable conditions for the support of breastfeeding, for example, respecting the maternity leave, milking in the workplace and time of work, access to children day care or conditions for breastfeeding [9].
It is important to educate mothers who work in relation to their rights.The 1988 Federal Constitution guarantees that women with formal work (officially registered) are entitled to several benefits, such as maternity leave of 120 days under the Consolidated Labor Laws.In turn, the Corporate Citizenship program encourages companies to extend the maternity leave of their workers for 6 months.That law has become of paramount importance in the country, because it meets the recommendation of the World Health Organization (who) and the Health Ministry to "exclusive breastfeeding for 6 months".Many States and municipalities are already granting this license to their employees [11/10/12].
Table 4 indicates that baby weaning occurred before the pediatric recommendation.Early weaning has been shown to be a major barrier to be faced, conditioned by cultural, emotional, family, educational and social factors.In addition to these elements, it is understandable that the form of care provided by health professionals and the quality of the information provided by these professionals, even if unintentionally, is collaborating to reduce the practice of breastfeeding [13].
About 54% of women report the introduction of artificial milk before the recommended age (Figure 1).It's worth noting that the practice of breastfeeding is seen as prevention of over 6 million deaths in children under 12 months, each year.If breastfeeding were exercised universally, more than 2 million deaths could be prevented.A study reveals that the practice and the success of breastfeeding is possible, however, mothers need ongoing support during pregnancy, prenatal consultations and after delivery, and not just by their families and friends, but especially by nursing professionals [14].
According to Figure 2, it is noted that mothers have access to information on breastfeeding, although it is not possible to verify in this study its extension and adaptation to mother's and child's bio-psychological condition.Generic guidelines on breastfeeding does not offer the same effectiveness to individualized counseling, as the latter tries to understand the doubts, fears and perceptions of pregnant women about the act of breastfeeding.Generic guidelines, in turn, disregard the different socio-emotional and physical variables involved in breastfeeding.
According to the presence of nursing orientation in 72% of respondents reports (Table 5), we can note that the nursing professional is the most important one in the success of breastfeeding, by having many opportunities of contact with pregnant women, their infants and mothers, in the different levels of health care.So they have ample chances to expand actions, identify and enhance educational occasions, promoting breastfeeding [15].
The practices of promotion, protection and support of breastfeeding must happen proactively, and be expanded in prenatal care and followed by the breastfeeding encouragement in order to support the nursing action programs, allowing for greater attention, improving the women, children and family healthcare [15].
Data show that only a small percentage of mothers, 28% (n = 14) has extended breastfeeding up to child's first two years of life (Figure 3), being more common that breastfeeding practice is suspended before the first year of child's life.Thus, you can see that breastfeeding is early removal of the child's life and replaced by other food means that are not necessarily healthy alternatives to child development.
Results show 80% (n = 40) of the participants say that the decision was based on the mother's own initiative in introducing artificial milk (Table 6).This data reveals that despite all the benefits breastfeeding offers for mother and baby, the practice of exclusive breastfeeding still suffers the influence of several factors (cultural, socioeconomic, biological, demographic), which interfere in a negative way on the practice and successful breastfeeding.It is noted that, either by mother's characteristics, or by external factors, many of them are introducing artificial milk long before the time it is recommended, which leads their children to a lower intake of breast milk.
The early interruption or absence of breastfeeding, and the introduction of other foods, such as formula milk to the child, before their first six months of life, are constant, with important implications for the health and wellbeing of the baby, as contact with foreign proteins, exposure to infectious agents, damage to digestion and identification of nutrients, among other aspects [6].

Conclusions
The set of results of this study indicated that most mothers received some counseling about breastfeeding.However, even having access to information, baby weaning occurred before the pediatric recommendation, being the return to work the most mentioned cause of the impossibility or difficulty of breastfeeding maintenance for mothers participating in the study.
Since breastfeeding is a procedure to be encouraged in community health spaces, the relevance of this study for Nursing is to observe the breastfeeding act as a natural and social behavior, influenced by the dominant culture, which in itself can inhibit or facilitate breastfeeding, and also as an act that serves as an outwit or confirmation of a possible cause for diseases in childhood, or even the propensity to them. in this way, the contact with the literature or training actions for nurses on the topic can be important to generate changes in attitudes and behaviors adopted by mothers and lactating women.This is even more relevant if we consider that only by mobilizing the players involved in breastfeeding it will be possible to obtain effective practices in terms of the increased incidence of exclusive breastfeeding.It is further understood that only the deep knowledge of the aspects that influence and affect breastfeeding, especially in the first six months of child's life, will help to promote breastfeeding, and the formation of conscious and confident lactating women.
Thus, it is essential to replicate the performed research in order to introduce and explore new data on the subject, analyzing other variables that may be imbricated in breastfeeding behavior, studying, for example, its association with motivation and social beliefs, as well as building tools targeted to nursing professionals, with validity evidence necessary to evaluate the type of instruction and advice received by pregnant women and lactating women on breastfeeding.

Figure 1 :
Figure 1: Descriptive analysis on exclusive feeding and supplementary feeding.

Figure 2 :
Figure 2: Were you informed about breastfeeding during pregnancy?

Figure 3 :
Figure 3: Are you breastfeeding your baby nowadays or any child under two years old?

Table 2 .
Descriptive analysis related to the benefits of breastfeeding for the baby and the mother.(n=50).

Table 3 .
Descriptive analysis of the reasons that lead to early breastfeeding cessation.(n=50).