5157en

ORIGINAL ARTICLES

 

Cross-breastfeeding, from negligence to moral virtues: a descriptive study

 

Cristiane Santos Gomes1, Juliete dos Santos Amaral Fonseca1, Patrícia Lima Pereira Peres1, Benedita Maria Rêgo Deusdará Rodrigues1

1State University of Rio de Janeiro

 


ABSTRACT
The study aims to understand the practice of cross-breastfeeding performed by nursing mothers living in the municipalities of the Baixada Fluminense. To this end, we chose to use a descriptive method and used a qualitative approach and carried out structured interviews and content analysis. The study participants were fifteen(15) women aged more than 18 years, who are breastfeeding or have already breastfed, residents in the municipalities of Belford Roxo and Duque de Caxias in the period between April and May 2014. The results show that the practice of cross-breastfeeding is motivated by moral virtues and behavioral patterns, and it is a subject neglected by health professionals.
Conclusion: to put an end to this practice that leads to vertical contamination, it is necessary to redirect those virtues for establishing and strengthening a support network associated with a health education system that includes cross-breastfeeding and is promoted by the professionals who assist them.
Descriptors: Breast feeding; HIV; Ethics; Nursing.


 

INTRODUCTION

Breastfeeding is widely encouraged as the most complete food source since it is ideal for child growth and development and it brings advantages for the nursing mother, the baby and society/nation. It is exclusively recommended until the sixth month of life and complemented up to two years or more, except for infectious cases such as mothers affected by HIV (Human Immunodeficiency Virus), human lymphotropic Virus of T cells (HTLV 1 and 2) or when the child has a metabolic disorder that contraindicates it(1).

An important contraindication is the HIV infection, which had its advent in the late 70s of the last century and has since been a prevalent disease worldwide(2,3).

Among the sources of HIV infection is breast milk, as this is the primary source of virus infection in children(4). This justifies the recommendation to ban cross-breastfeeding, that is, the practice of offering breast milk directly from the breast or expressed to an infant other than the person’s own child(5) by the World Health Organization (WHO), United Nations Fund for Children (UNICEF), and adopted by the Ministry of Health of Brazil.

In a study that aimed to evaluate the incidents reported between the years 2008 and 2012 in a large hospital in southern Brazil, it was observed that cross-breastfeeding was present in 14 (1.9%) of cases(5), and this could cause damage to the baby's health.

Another work carried out in a maternity hospital in the São Paulo countryside showed that, among the 17 mothers interviewed, 15 agreed to breastfeed another’s baby and another 16 agreed that her baby was breastfed by another woman(6).

It is worth noting that in developing the management of breastfeeding amongst women living in different municipalities of Baixada Fluminense, cross-breastfeeding appeared as a frequent practice among the women assisted, which aroused the need to understand the reasons for this habit that, since 1980s, is no longer recommended.

In addition, the search in the databases LILACS, SciELO and BDENF, without limitation in time, including the keywords "breastfeeding" and "HIV", resulted in 32 publications covering topics such as the impossibility of breastfeeding, prevention of mother-child transmission, and communication between mother and the child suffering from HIV/AIDS. After a more refined search with the keywords "breastfeeding", "HIV" and "nursing", no material was found.

Thus, this study has the general objective to understand the practice of cross-breastfeeding performed by nursing mothers living in municipalities of Baixada Fluminense. The specific objectives are to identify the position of mothers in relation to cross-breastfeeding and its practice; describe the reasons reported by the mothers; identify if there was guidance from a health professional; and discuss the role of nurses in the prevention of this practice.

This study is considered significant due to the insight into the mothers' knowledge in terms of cross-breastfeeding, as this helps to identify the factors that lead to such activity and thus (re)consider what actions can be taken to avoid its occurrence and prevent health damage to the child.


THEMATIC REFERENCE
The practice of wet nurses (act of breastfeeding the child of another woman) is a historical and cultural issue. It appeared in Brazil in the nineteenth century as mercenary breastfeeding, a condition in which women who could not breastfeed and had financial resources were advised to hire a wet nurse at home by means of remuneration, thus stimulating the permanence of children with them most of the time(7).

In the ads for selling or renting these wet nurses, the owner highlighted their qualities: no vices, diseases, with good manners and recent pregnancy, that is, new milk, good health condition(8).

From the mid-nineteenth century, the constant epidemics of yellow fever and cholera influenced doctors’ decision to insist that white babies should be suckled by their mothers(8).

In the late twentieth century, cross-breastfeeding was officially banned in Brazil according to the recommendation of WHO of 1989, when there was an understanding that human milk is a source of HIV infection. Vertical transmission accounts for 84% of AIDS cases known in Brazilian children, and breastfeeding represents an additional risk of transmission estimated between 7% and 22%(9).

Studies reveal that vertical transmission of HIV can occur during pregnancy, childbirth and postpartum. In the latter, the risk is higher in the first months of breastfeeding(10,11).

From 2000 to June 2013, a total of 77,066 cases of HIV infection in pregnant women have been reported in the Notifiable Diseases Information System (SINAN), and 32,136.5 of these cases (41.7%) occurred in the Southeast Region(12).

This implies a social and public health problem: the increasing vertical transmission of HIV in the country.

Given the above, the proper implementation of all the preventive measures from mother to child transmission becomes necessary; therefore, we should be attentive to cross-breastfeeding as an additional risk.

It is noteworthy that breastfeeding is a biologically determined act, but its effectiveness depends on social, cultural, historical and psychological factors of the mothers and of the commitment and knowledge of professionals who assist them. Health professionals must identify and understand the process of breastfeeding throughout the family and socio-cultural contexts and thereby promote proper health education in each reality situation.

 

METHOD

This is a descriptive study using a qualitative approach. The field for its execution was the municipalities of Belford Roxo and Duque de Caxias, both in Rio de Janeiro. The study was conducted through interviews with women intentionally chosen by the researchers based on the following inclusion criteria: the participants were women aged 18 years or more, and who were breastfeeding or have breastfed. The exclusion criteria were: participant under 18 years of age, never having breastfed, and living in different cities.

Each researcher was responsible for data collection in a municipality. The first candidate interviewed in each city was intentionally selected by the researchers and was approached in her own residence upon meeting the inclusion criteria. Thus, we have indicated the following women up to the saturation of information in both municipalities. This method, known as snowball or "chain of informants," is a sampling technique that aids in the study participants reference chain (13). The scenario was diverse in the municipalities concerned, with women from different neighborhoods (as this is Baixada Fluminense, all participants have similar socio-economic and cultural characteristics).

Data collection took place between April and May 2014. It was carried out through a structured interview with profile identification data of the respondents and 14 questions addressing the following questions: the number of children who were breast-fed; whether the participants or someone in their families had practiced cross-breastfeeding; whether an HIV testing had been conducted; whether they allowed, or would allow their children to receive breast milk from another woman; whether they believe there is any contraindication associated with the practice; and whether a health professional provided guidance on the subject.

All interviews were conducted individually, united by time and place. The participants were told about the objectives and importance of the research as well as their consent to the recording of speech after acceptance and signature of Informed Consent (IC). To comply with the procedures provided for in Resolution No. 466/2014 of the CNS/MS, the project was submitted and approved by the Research Ethics Committee (COEP) of the Rio de Janeiro State University (UERJ) under opinion No. 613,220.

Data analysis was carried out through the content analysis method proposed by Minayo(14). In the first data preparation stage, that is, of audio recordings of the interviews, the speeches were transcribed to provide a record of what was said. The second stage consisted of the exploration of the material in which the data were organized into categories. The last stage consisted of analyzing and interpreting the results by means of inferences and interpretations that was done by correlating them with the theoretical framework.

The research faithfully followed the steps proposed by Minayo, which are:
a) Data order: transcription, rereading the material, report organization.
b) Data classification: questioning in terms of the references based on a theoretical basis.

 

RESULTS

Based on the profile of the participants, it was found that: 10 are married, 10 also have high school degree, 8 of the 15 respondents reported having practiced cross breastfeeding at least once and the others claimed that they did not do it for lack of opportunity, 10 women reported the occurrence of cross-breastfeeding by a family member, 3 declined, and two were unable to inform. Among them, 10 believe there is some contraindication for cross-breastfeeding, and 5 think there is nothing that contraindicates cross-breastfeeding.

From the general and comprehensive reading of excerpts from the speech of the interviewees, and of the exploitation of the material and content analysis three categories were revealed:
1) The practice of cross-breastfeeding motivated by moral virtues: solidarity, wellness and trust.
2) The practice of cross-breastfeeding based on behavioral and cultural patterns.
3) Cross-breastfeeding as a theme neglected by health professionals.

The practice of cross-breastfeeding motivated by moral virtues: solidarity, wellness and trust

Solidarity
Although the interviewees recognized possible contraindications, the practice from an altruistic perspective seeks to correct a perceived evil generated by non-breastfeeding, which is considered highly detrimental.

For women, this act symbolizes solidarity, since mothers intend to help those who cannot breastfeed their children for any one of several reasons (work or study, far away from their homes, low milk production or problems in the breast that makes breastfeeding impossible). The speech below shows that cross-breastfeeding appears as a solidary alternative, corroborating the study that reports the case of a two-month-old baby being suckled by the paternal aunt: the motivation is the need for the mother to return to work(10).

In the hospital where I was admitted this time, I did not have much milk, then my roommate breastfed my son. Then, just as others did for me, I should do for others. (E2)

Wellness
Wellness is another moral virtue identified as a guide to cross-breastfeeding in the statements of the women. Wellness, in the Aristotelian sense, is the purpose of man; in a hierarchical scale, happiness is the supreme good(15), wellness, as a result therefore has a sense of value and not transitory welfare.
It is good for me and for the child. (E10)

I think it's a very generous act, especially because the pleasure of breastfeeding a child is amazing. (E9)

It is noted that, for the participant, the practice of cross-breastfeeding is surrounded by satisfaction from the perspective of the wellness provided to the child.

Trust
Cross-breastfeeding was identified by participants as a beneficial solidary practice that only materializes from the relationship of trust with each other. This can be seen in the following lines:
I don't care. As she belongs to my family I don't even care. (E2)

If the mother trusted me and let me suckle her son or vice versa. (E4)

The interviewees stated that they allow their children to be suckled by other women, establishing a relationship of trust with love as a criterion. However, this rule is based on dubious concepts and, in some cases, without any scientific evidence.

The practice of cross-breastfeeding based on behavioral and cultural patterns.
This category is based on the hygienist thought, which advocates that, in order to breastfeed another child the "ideal" woman must be clean, free from diseases, close to the family, have had recent exams and be an ethical person. This thought came in the following lines:
I think I would do it [...], but I would have to do the exams in order to be experiencing something in a healthy way. I would do it, for sure. (E3)

Only if you have a disease like AIDS, have bodily injury or if this is not a very clean person. (E12).

] if it is a person like: "this is not an ethical person, is not a good-natured person; is a person who will not look at my son with the same love and affection I look, "then it would be someone I would discard. (E7)

The confluence of scientific and popular knowledge is present in the speeches that blend technical, moral and common sense contraindications. Culture has a b influence on the attitude of the people, since through it the experience of cross-breastfeeding is transmitted and encouraged by the family to their offspring, based on their daily experiences:
Because the human being has a habit of repeating what he sees in everyday life, in living [...], so that is why I believe I would encourage. (E4)

So, at that time when my mother nursed my niece [...] she offered (herself to breastfeed the baby) and I saw that as an incentive for me [...]. (E7)
The family is, in every way, the locus necessary for the promotion of breastfeeding from an autonomous perspective.

Cross-breastfeeding as a theme neglected by health professionals
All interviewees reported they were not oriented on this subject at any time.

As for the work of health professionals, all interviewees talked about the importance of guidance on this issue, as they claim that the absence of this knowledge can have serious consequences for the child. Thus, it is clear that the cross-breastfeeding is a topic still overlooked by professionals.

(...) A lot of people do not have this knowledge, and this generates consequences for the child, then it is important [...] the guidance of a professional [...] (E14)

For lack of the knowledge of contraindication in terms of cross-breastfeeding, some mothers still did it at the hospital. When they were surprised by health professionals with this knowledge, they felt embarrassed.

And also for lack of guidance on prenatal care, no one had explained it, so I allowed it. Then a nurse came to me and told me off. (E6)

For me everything was normal till the nurse came and told me off. She scolded me because I was nursing a child who was not mine. (E7)

In the above lines, it is clearly observed the lack of knowledge concerning cross-breastfeeding. As this issue is not presented to them and clarified, how can they know whether this is beneficial? Instead, the opportunity to do good for others contributed to the practice.

 

DISCUSSION

For healthcare professionals breast milk is a source of nutrients, protective factors and prevention against health problems and its range is put into effect through public policies, health education and good professional practice(16). For the women who practice cross-breastfeeding in this study, the moral virtues that guide human relations were the main motivations. Thus, in many cases, moral virtues are the tools that nursing mothers find to ensure the supply of nutrients and protective factors so necessary for children and accessible through solidarity, goodness and trust.

It is worth mentioning that the moral virtues are guiding values of human conduct, since they aim for a fair end (telos). “A virtue is mainly the balance between what is good for you and what is good for the other”(17). Regarding solidarity as a virtue, it is worth stating that "giving the other what he lacks and not necessarily what is rightfully his is the magnanimous character of virtue"(17).

The statements converge to the understanding that there is a collective way of dealing with the limitations of breastfeeding. On that thought and the collective action: "in the domestic sphere of a community there may be a translation of thought, customs and loyalty that allows you to build any valid principle for all its members"(18).

Several phrases of encouragement were spread horizontally through the media among their own mothers. It is true that the aim of the national breastfeeding policy is to disseminate the culture of breastfeeding; however, one cannot lose sight of the singularities. In the educational process it is necessary to inform people of the existence of cases in which there will be the need for replacement of human milk for child protection, such as when the mother is HIV positive.

Breast milk gives the child protection to several pathologies and it also resonates in a good emotional and cognitive development(5). These properties mean that it is the first choice made by the mother herself, allowing the child not to lack anything and consequently damage to health.

This view of breast milk as a "vaccine", bly disseminated in the services and in the media, is not always understood in all its complexity. When referring to breastfeeding we are strengthening not only the importance of breastfeeding, but above all, of the mother’s breastfeeding. This is not just about offering human milk, but the milk from the mother to her child. Nevertheless, one should pay attention to exceptional situations.

A trust relationship, as a necessary factor for the occurrence of cross-breastfeeding, is established by the fact that the practice is usually done with someone who has a link, or is someone close, to the family, someone who also shows good health and that has undergone all examinations during pregnancy, among other features.

We realize that these women might still have been thinking of hygiene issues when they informed us that cross-breastfeeding would not happen solely because the "wet nurse" presented risks to the children's health. For the study participants, a person with good health is one who has good living habits, does the tests recommended during pregnancy, and also has good moral and ethical conduct.

In the nineteenth century, doctors had the thought that breast milk conveyed moral characteristics from the nursing mother to the baby, determining the character of the child. To minimize problems, a project created by Moncorvo de Figueiredo forced slave wet nurses to undergo a rigorous examination to have a "quality certificate"(19).

The occurrence of cross-breastfeeding by a family member has proven to be an act culturally transmitted, considering that breastfeeding is a natural practice and suffers social influence. Culture is transmitted in every moment of life and influences the way of being of the people. " ] The moral and ethical values of the family, developed in its genesis and culturally transmitted, pervade their relationships and sustain the ways of living within the family"(11).

There is a mark of the influence of culture in the statements of the participants derived from the list of previous experiences and encouragement of their families, which reinforce their views on cross-breastfeeding and strengthen their attitudes.

Nurses are professionals are very close to women during pregnancy and childbirth. At all stages, they need to play their role to inform, guide, support and advise. From this teaching perspective, nurses should offer support so that women can build knowledge from their own experience, making it possible for them to incorporate new knowledge successfully. Nurses must understand that counseling and teaching do not mean a transfer of knowledge(20). However, through this study we have shown a gap in guidance related to assistance in terms of cross-breastfeeding.

The way that health professionals approach mothers to educate them in terms of breastfeeding also affects its process. There must be an understanding related to the feelings of women against this practice, their reasons for breastfeeding the child of another woman or to allow her child to be breast-fed by another woman. Professionals must have communication skills in order to be available and help them with their complaints, fears and concerns, as there should be no impositions, but rather a contribution to the knowledge, autonomy and decision-making of these women, thus increasing their self-confidence and self-esteem.

As seen in the results, some mothers did not receive guidance in terms of cross-breastfeeding and were scolded when practicing this act still in the maternity ward. However, scolding is not a method to educate - it is the opposite of educating, causing embarrassment to the individual when it happens. Potentially these persons will practice the same behavior again, because only telling somebody off does not lead the subjects to reflect on their actions, while guidance and counseling lead to reflection-action-reflection, generating dialogue and not a monologue.

Nurses are educators and opinion makers and should encourage critical thinking, reflection and the exchange of ideas in the dialogues with the people they care for. Each individual is a unique being, socially and historically constituted, who learns through interaction with his own environment; but in order to achieve this education must be contextualized within the reality of the situation(20).

Therefore there must be a responsible way to fully guide women, leaving no gaps that can be harmful. To obtain this situation, an ethical attitude of professionals in providing clarification to women is expected, not just warning them when the act has already been accomplished by the lack of prior guidance.

 

CONCLUSION

There are several strategies used by health professionals to promote breastfeeding, which arguably have important consequences in changing the practice of many Brazilian mothers. However, the massification in terms of the importance of breast milk and its superiority over other dairy substitutes, dissociated from an educational and reflective process, can obscure the risks that human milk can pose when it is not the mother’s or from the human milk banks.

Cross-breastfeeding is a culturally accepted practice in the scenarios of this study, justified by moral virtues such as solidarity, good and trust.

The study demonstrated that breast-feeding, and particularly cross-feeding, is a clear example of "moral action" in which the first two categories indicate the choices made by the women participating in the study. For them, being supportive to each other and doing good to the child were legitimate motivations and, although some of them knew the contraindications, it was their trust that made the act possible.

The third category brings light to the first two, since the free and autonomous choice is not possible if there is insufficient knowledge. Therefore the imposition without clarification in terms of the harms of cross-breastfeeding (as was seen in the speeches) is a key element for the continuation of this practice.

Cross-breastfeeding is far from being an exhausted subject, whether from the scientific and research point of view, or from the assistance as a multi-professional practice. In terms of nursing, seeking a libertarian, critical and independent practice for the different subjects they care for, the research shows the need for deeper investigation of the subject, in order to understand the professional nursing practice. Other studies on cross-feeding can contribute to a better understanding of the phenomenon of child transmission of AIDS and the impact on its magnitude.

Thus, the research contributes to the understanding of comprehensive care and adequate assistance, which is guided by the knowledge of the nursing mothers to prepare action plans that can intervene in the course of cross-breastfeeding. For professionals, the study works as evidence so that the topic of cross-breastfeeding, so often forgotten, is included in the approach to breastfeeding with mothers.

 

REFERENCES

1. Andrade ISN. Breastfeeding and its benefits: the first step to health promotion. Rev Bras Promoç Saúde [ internet ]. 2014 [ cited 2014 may 10 ] 27(2):151-152. Available from: http://ojs.unifor.br/index.php/RBPS/article/view/3442.

2. Oliveira MIC, Silva KS, Gomes Junior SC, Fonseca VM. Delivering rapid HIV tests results after delivery: a threat to breastfeeding at birth. Rev. Saúde Pública [ internet ]. 2010 [ cited 2014 may 10 ] 44(1):60-69. Available from: http://www.scielo.br/scielo.php?pid=S0034-89102010000100007&script=sci_arttext.

3. Silva DP. A representação social do ser humano para homens heterosexuais e a vulnerabilidade para o HIV/AIDS. Rio de Janeiro. [ Dissertação ]. Rio de Janeiro:Universidade do Estado do Rio de Janeiro; 2014. 

4. Prestes-Carneiro LE, Spir PRN, Ribeiro AA, Goncalves VLMA. HIV-1-mother-to-child transmission and associated characteristics in a public maternity unit in Presidente Prudente. Rev. Inst. Med. trop. S. Paulo [ internet ]. 2012 [ cited 2014 may 12 ] 54(1):25-29. Available from: http://www.scielo.br/scielo.php?pid=S0036-46652012000100005&script=sci_abstract.

5. Lorenzini E, Santi JAR,  Bao ACP. Patient safety: analysis of the incidents notified in a hospital, in south of Brazil. Rev. Gaúcha Enferm.  [ Internet ]. 2014 [ cited 2014 jun 17 ] 35 (2): 121-127. Available from: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1983-14472014000200121&lng=en

6. Nogueira CMR. Conhecimento sobre aleitamento materno de parturientes e prática de aleitamento cruzado na Unidade Hospitalar e Maternidade Venâncio Raimundo de Souza. [ Dissertação ]. Fortaleza: FIOCRUZ; 2008.

7. Bosi MLM, Machado MT. Amamentação: um resgate histórico. Cadernos Esp- escola de saúde pública do Ceará [ on line ]. 2005 [ cited 2014 jun 17 ]. Available from:http://www.esp.ce.gov.br/cadernosesp/index.php/cadernosesp/article/view/4

8. Koutsoukos SSM. ‘Amas mercenárias’: o discurso dos doutores em medicina e os retratos de amas – Brasil, segunda metade do século XIX. História, Ciências, Saúde–Manguinhos [ internet ]. 2009 [ cited 2014 jun 18 ] 16:305-324. Available from: http://www.scielo.br/scielo.php?pid=S0104-59702009000200002&script=sci_arttext

9. Santos, EM, Reis AC, Westman S, Alves RG. Avaliação do grau de implantação do programa de controle da transmissão vertical do HIV em maternidades do “Projeto Nascer”. Epidemiol. Serv. Saúde [ internet ].2010 [ cited 2015 jul 24 ] 19(3):257-269. Available from: http://scielo.iec.pa.gov.br/scielo.php?pid=S1679-49742010000300008&script=sci_arttext

10. Ntia HU, Udo JJ, Eyong ME. HIV transmission to an infant from cross nursing: a case repor. tJ Paed [ internet ]. 2014 [ cited 2015 jul 24 ]41(1):78 –80. Available from: http://www.ajol.info/index.php/njp/article/view/96967/86274  

11. Kindra G, Coutsoudis A, Esposito F, Esterhuizen T. Breastfeeding in HIV Exposed Infants Significantly Improves Child Health: A Prospective Study. Maternal and Child Health Journal [ internert ]. 2012[ cited 2015 jul 24 ] 16(3):632-640. Available from: http://link.springer.com/article/10.1007/s10995-011-0795-8

12. Ministério da Saúde (Brasil, Secretaria de Vigilância em Saúde. Boletim Epidemiológico - Aids e DST Ano II - nº 1. Brasília: Ministério da Saúde; 2013.

13. Baldin N, Munhoz EMB. Snowball (bola de neve): uma técnica metodológica para pesquisa em educação ambiental comunitária. In: Anais do X Congresso Nacional de Educação. I Seminário Internacional de Representações Sociais, Subjetividade e Educação; 2011; Curitiba [ Internet ]. [ cited 2014 jun 20 ]. Available from: http://educere.bruc.com.br/CD2011/pdf/4398_2342.pdf

14. Minayo MCS. Pesquisa Social: Teoria, método e criatividade. 31. ed. Rio de Janeiro: Vozes; 2012.

15. Passanha A, Benicio MHD, Venancio SI, Reis MCG. Implementation of the Brazilian Breastfeeding Network and prevalence of exclusive breastfeeding. Rev. Saúde Pública [ Internet ]. 2013 [ cited 2014 jun 20 ] 47(6):1141-1148. Available from: http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S0034-89102013000901141&lng=en

16. PEGORARO, O. Ética dos maiores mestres através da história. 4ª Ed. Petrópolis, RJ: Vozes, 2010

17. Tognetta RLP, Assis OZM. A construção da solidariedade na escola: as virtudes, a razão e a afetividade. Educ. Pesqui. [ internet ]. 2006 [ cited 2014 jun 22 ] 32:49-66. Available from: http://www.scielo.br/pdf/ep/v32n1/a04v32n1

18. D´aurea-Tardeli D. A manifestação da solidariedade em adolescentes: um estudo sobre a personalidade moral. Psicol. cienc. prof. [ internet ]. 2008 [ cited 2014 jun 26 ] 28:288-303. Available from: http://www.scielo.br/scielo.php?pid=S1414-98932008000200006&script=sci_arttext

19. Carula K. Perigosas amas de leite: aleitamento materno, ciência e escravidão em A Mãi de Família. História, Ciências, Saúde - Manguinhos [ internet ]. 2012 [ cited 2014 jun 26 ] 19:197-214. Available from: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0104-59702012000500011

20. Freire P. Pedagogia da autonomia: saberes necessários à prática educativa. São Paulo: Paz e Terra; 1996.

 

 

All authors participated in the phases of this publication in one or more of the following steps, in According to the recommendations of the International Committee of Medical Journal Editors (ICMJE, 2013): (a) substantial involvement in the planning or preparation of the manuscript or in the collection, analysis or interpretation of data; (b) preparation of the manuscript or conducting critical revision of intellectual content; (c) approval of the versión submitted of this manuscript. All authors declare for the appropriate purposes that the responsibilities related to all aspects of the manuscript submitted to OBJN are yours. They ensure that issues related to the accuracy or integrity of any part of the article were properly investigated and resolved. Therefore, they exempt the OBJN of any participation whatsoever in any imbroglios concerning the content under consideration. All authors declare that they have no conflict of interest of financial or personal nature concerning this manuscript which may influence the writing and/or interpretation of the findings. This statement has been digitally signed by all authors as recommended by the ICMJE, whose model is available in http://www.objnursing.uff.br/normas/DUDE_eng_13-06-2013.pdf

 

 

Received: 02/05/2015
Revised: 08/17/2015
Approved: 08/18/2015