ORIGINAL ARTICLES

Breastfeeding as an evaluative practice in know-how: a descriptive study

Valdecyr Herdy Alves¹, Diego Pereira Rodrigues¹, Bruno Augusto Corrêa Cabrita¹, Bianca Dargam Gomes Vieira¹, Maria Bertilla Lutterbach Riker Branco¹, Angela Mitrano Perazzini de Sá²

¹Fluminense Federal University
²Municipal Secretariat of Health of Rio de Janeiro

ABSTRACT
Aim: To analyze the axiological dimensions of nurses regarding breastfeeding and their reflections along with the nursing mothers, in the process of knowledge transmission.
Method: A descriptive and qualitative study of 11 nurses from the Friendly Breastfeeding Primary Care Initiative of Rio de Janeiro. The data were collected by means of semi-structured interviews between January/March 2010, generating categories articulated with Max Scheler’s Theory of Values.
Result: The following categories emerged: the affective bond as a value for successful breastfeeding; and breastfeeding and nutritional value and protection for the child.
Discussion: To analyze the evaluative link of the act of breastfeeding between mother and child and the link related to the value of food safety also means thinking about the love and affection that, in the conception of Scheler, are absolutely unique.
Conclusion: the valuation of women as individuals is seen through a totally new perspective concerning breastfeeding, as recommended by public policies regarding women’s care.
Descriptors: Nursing; Social Values; Milk Human; Breast Feeding

INTRODUCTION

The act of breastfeeding is ancient, has no cost and is essential for humans. Breastfeeding is not only influenced by natural and biological aspects, but it is also affected by the everyday life of families in their social and cultural environments ⁽¹⁾. This means that breastfeeding has different connotations according to various cultures, making its practice a habit related to social determinants and cultural manifestations, and influenced by the same conceptions and values indicated in the process of socialization of women⁽²⁾. So we ask: what is breastfeeding? What is the meaning of it?

Breastfeeding means providing breast milk, the mother holding her child closely to her breast; nursing, lactating, feeding, nourishing. Suckling is a synonym of breastfeeding, referring to the same functional impact of nursing or raising the child with milk produced by the mother. Therefore, the meaning of each word is not restricted to the purely biological aspect of the action, but rather exceeds it by translating the emotions surrounding a woman's relationship with her child, family and the world around her⁽³⁾.

In a survey conducted by the Ministry of Health (MOH) in all state capitals and the Federal District, collecting data relating to 34,366 children, it was found that the average duration of breastfeeding increased in the capitals and the Federal District, from 296 days in 1999, to 342 days in 2008. In the same period and locations, the average duration of exclusive breastfeeding reached 51.1 days (1.8 months), while breastfeeding supplemented by other foods was 341.6 days (11.2 months)⁽⁴⁾.

The practice of breastfeeding is initially implemented in the first hour after birth and encouraged during the postpartum period; in many situations, however, it causes fear, insecurity, conflicts, anxiety, physical discomfort and even depression for the lactating women, who can adopt complementary and/or artificial breastfeeding, thus damaging the breastfeeding process⁽⁵⁾.

The increase in the average length of breastfeeding in Brazilian capitals is due, to a large extent, to the National Program to Encourage Breastfeeding, created in 1981 by a government agency, combining multisectorial actions, particularly in the areas of media, healthcare and legislation⁽⁶⁾. The rates achieved are, however, still quite distant from the recommendations of the World Health Organization (WHO) and the United Nations Fund for Children (UNICEF), which propose exclusive breastfeeding for six months and breastfeeding supplemented by family food up to two years of age or older⁽⁷⁾.

The strategy of the Baby Friendly Hospital Initiative (BFHI) recommends implementation of the ten steps to successful breastfeeding, amongst which step five stands out which indicates that it is necessary to show mothers how to breastfeed and maintain lactation, even if they are separated from their infants. This measure guides the clinical management of breastfeeding, helping the fourth goal of the Millennium Development Goals to reduce child mortality⁽⁸⁾.

Accordingly, in order to encourage and equip the basic health network to deploy a set of procedures for the promotion, protection and support of breastfeeding in the primary health network services, the Municipal Secretariat of Health and Civil Defense of Rio de Janeiro (SMSDC-RJ), pioneered in 1999 the Breastfeeding Friendly Primary Care Initiative (BFPCI) in eleven basic health units. It is noteworthy, however, that there was a prevalence of 40.7% for exclusive breastfeeding and 58.3% for breastfeeding in the state capital, in 2009⁽⁹⁾.

These numbers are lower than expected for breastfeeding in the city of Rio de Janeiro, where protocols have been established regarding the clinical management of breastfeeding to assist women. It is the responsibility of the BFPCI to make breastfeeding a universal practice, thus contributing significantly to the health and well being of the mothers and babies.

In this context, the process of assessment of breastfeeding, allows us to understand the woman in her essence, existence and values, since it constrains the values inherent in human existence as evoked by Scheler. The foundation of Scheler's axiology focuses on values, whose preconceived principles are regarded as objects made of non-formal essence, that is, existence precedes the being’s existence⁽¹⁰⁾. In this sense, the values assigned to breastfeeding by nurses acting in this practice allow the understanding of their existence in their professional practice.

Given the above, and to examine the multiple aspects involved in the practice of care of breastfeeding women, we established the following objective: to analyze the axiological dimension of nurses regarding breastfeeding and its reflections along with nursing mothers in the process of knowledge transmission.

METHOD

This is a study of a social, descriptive nature, in which a qualitative approach was used, aiming at examining subjective data regarding breastfeeding. The investigation was carried out with the approval of the Ethics Committee in Research SMSDC/RJ under protocol 62/09 of December 20, 2009, according to Resolution 466/12 of the National Health Council⁽¹¹⁾.

The research was conducted in 11 Breastfeeding Friendly Basic Units, located in the municipality of Rio de Janeiro. All these units have a breastfeeding room for the care of women, the baby and the family, and these are considered as reference units for the specialized monitoring of mothers and babies with regard to breastfeeding.

The inclusion criterion for the subjects was that of nurses working in the Breastfeeding Program of IUBAAMA. In order to meet this criterion, the study sample comprised ⁽¹¹⁾ nurses. All the nurses voluntarily signed a consent form; anonymity and confidentiality was achieved by means of an alpha-numeric code (N1 to N11) in the analysis and discussion of data. Nurses working for less than six months in the sector were excluded from the study because we considered this period insufficient for acquiring experience of the routines of the sector; training for working in this sector lasts six months.

Individual semi-structured interviews were chosen for data collection, which occurred between January and March 2010, in the participants’ work units.

The interviews were recorded on tape, transcribed by the researchers and validated by the interviewees.

The construction of the qualitative data, as well as the thematic categories was based on Bardin⁽¹²⁾ and thematic analysis was based on Scheler’s Theory of Values⁽¹⁰⁾. This facilitated the discussion and establishment of the point of view of the interviewees in order to achieve the aim of the study. Two thematic categories emerged from the data, namely: the affective bond as the value for breastfeeding success; and breastfeeding’s nutritional value and protection for the child.

RESULTS

Categorization of research subjects

Eleven female nurses, 72% of whom were aged between 35 and 45 years of age with 72.7% of them having between 11 and 15 years of professional experience were interviewed.

Regarding the year of graduation, it was found that most nurses (66.6%) had graduated more than 10 years ago. This time was considered sufficient for them to adapt themselves to the changes arising from the staggering technical and scientific development.

All respondents had completed a qualification course on the topic of breastfeeding in the past five years, resulting in a positive perspective towards providing assistance based on scientific knowledge regarding the quality of health care for women, baby and family in issues related to the clinical management of breastfeeding.

The emotional bond as a value for successful breastfeeding

From the nurses' responses it became clear that breastfeeding promotes a  bond between the nursing mother and her child. This thinking is reflected in the statements below:

(...) To start my guidelines, I try to understand if there is a linkage, because I know that, when there is a bond between mother and baby, everything is easier and breastfeeding is better. But when there's no bond, or there is no linkage in the family, everything becomes more difficult. (E8)

(...) I try to influence regarding the need to breastfeed because it allows the creation of a bond between mother and child, making things easier. (N5)

It is apparent that nurses are aware of the value of the bond created in the act of breastfeeding. They emphasize the value of their explanations to the mothers, linking these to the meanings the nursing mothers already carry within themselves, in order to involve them and obtain their full commitment to breast feeding. Below are some excerpts from the interviews about the importance of an affective attachment to successful breastfeeding:

(...) This is a process of construction [of the bond]. It does not depend only on us. (N1)

(...) I say that we just need to have a lot of affection and love in the family so that everything is easier. The bond is built within the family. (N3)

(...) I always say: breastfeeding should be built from the prenatal to the postpartum period. In these stages we can and must work to develop this bond, and then everything is easier. (N9)

Breastfeeding as a nutritional value and protection for the child

In this category, we highlight the vital values of survival, growth and development based on the understanding that breastfeeding promotes feeding, health and protection for the child.

(...) Breast milk is safe and it's ready. The woman doesn't have to do anything. She just needs to give the breast to the baby. Is there anything better than that? And on top of that it works as a vaccine. (E2)

(...) Breastfeeding is the first food safety of the baby, because it is rich in everything the baby needs. It doesn't lack anything, it's got minerals, protein, iron, water, IGG, IGM, that is, it's got everything he needs, right? (E6)

(...) They say that breast milk is good. I tell them that breast milk is the best food, it's a living liquid, with everything the baby needs. (N7)

Nurses explained how safe breast milk is for the baby, seeking to transmit this information to the mothers when providing further clarification about suckling. Whenever possible they were keen to emphasize the nutritional value of breast milk as good for the physical and mental state and is freely guaranteed to the baby.

(...) The baby who is freely breastfed until six months has more health, because he doesn't get sick easily. The milk has the proper nutrients for his growth and development, this is real. (N8)

(...) Breastfeeding means food safety. (...) It is a live food, it's different. When the mother needs to prepare infant formulas, who guarantees if the water is drinkable? (N11)

The following discourses exemplify the value placed on the biological model, perceived in nurses’ experience and work.

(...) Breastfeeding has the lowest cost, it's ready and comes in the perfect amount, and it has everything he [baby] needs; it is a healthy diet. (N1)

(...) Breast milk has many benefits for the baby when the mother provides it freely. This makes it easier for the baby to receive all the necessary nutrients to stay b and handsome, with immunity against some diseases. (N10)

(...) Not only the women with better financial conditions but also the ones with less money, provide benefits to their babies through breast milk. (...) We know that immunity is the basis for a healthy baby. (...) It's no use to give formula. We currently have children with morbid obesity and this is serious. (N5)

DISCUSSION

In the first category, "the affective bond as a value for successful breastfeeding" we observe that breastfeeding is a true manifestation of the bond, because we realize, affectively, the feelings of others without actually experiencing them. This perception is the first and fundamental condition of love. It is in this sense that love is created, since it seeks and discovers values that would, otherwise, remain hidden⁽¹⁰⁾. We presuppose the desire for the loved individual to reach personal fulfillment in order to achieve his potential.

In reflecting on the issue of the bond as an added value to the act of breastfeeding, we deduce that this appreciation corresponds to a constructive experience of a living being, because man is an evaluative being engaged in his own existence. And since breastfeeding permeates this bond, we deduce that such affection is directly linked to the affective value, as the relationship between the nursing mother and the child is a personal and unique experience of the human being, originating in the relationship provided by breastfeeding.

To consider the valorative linkage related to the act of breastfeeding also means thinking about love which, according to Scheler, is absolutely unique. In this sense, love is something essentially dynamic, involving focusing on each other while carrying a single and unique value. This is its true object; and additionally, love is spontaneous⁽¹⁰⁾.

Breastfeeding is one of the proofs of love of the mother for her child, because it generates great feelings of pleasure⁽¹³⁾. Following this line of thought, breastfeeding should also be considered as a fundamental strategy to the development of the attachment between mother and child⁽¹⁴⁾.

Nevertheless, the notion related to the value of this linkage consists in understanding that women are individuals who can choose to breastfeed their offspring or not. It is therefore related to the unconditional acceptance of reality and the values of the other.

Mothers’ understanding and acceptance of the importance of breastfeeding may represent for them an opening of pathways to new thoughts and attitudes toward life. Consequently, it is important for nurses’ discourses to take into account affective issues, because the decision to breastfeed is an act of love; the art of breastfeeding needs to be learned in essence by the mother and to be interpreted by her as one of many ways to express her love towards her child.

It is clearly perceived that the nurses refer to the act of breastfeeding as valuing affection and creating a bond. Thus, the nurses have a part to play in the relationship between the nursing mother and breastfeeding.

The practice of breastfeeding on demand should be guided and encouraged, as recommended by the Ministry of Health⁽¹⁴⁾, during and after pregnancy because it ensures the bond between mother and child.

It is therefore important to mention the importance of the availability of nurses to lactating woman, and the need for simple and objective communication that will guide, encourage and support breastfeeding.

Nurses should guide the nursing mothers regarding different breastfeeding positions, facilitating the relaxation and comfortable positioning of women, and should also explain the source of the child's reflexes and show how these reflexes can be used to help breastfeeding.

Given the above, it becomes evident that the nurse, when helping a lactating woman, must value not only breastfeeding, but also its positive effects, aiming to establish a meaningful affective bond between mother and child that will reverberate beneficially throughout the future of both. Therefore, it is not about the mere permanent contemplation of a given object, but we can assume the desired: that breastfeeding transcends its technical and scientific knowledge and affects for the nursing mothers in the full exercise of a vital value (breastfeeding).

In the second category, "breastfeeding as nutritional value and protection for the child" we consider that the act of breastfeeding permeates the vital values that are universal. We all need food, health and protection, which are basic elements for survival⁽¹⁰⁾. In order to achieve the goal of adequate nutrition, all societies ratify customs and concepts of life that can guarantee it. One of these practices is breastfeeding, recognized for its nutritional benefits for the child.

The professionals who work directly or indirectly in maternal and child healthcare unanimously recognize the superiority of breast milk rather than bottled milk for the baby, because it contains proteins, water, sugar and vitamins in balanced proportions that make digestion and assimilation easier for the newborn. These aspects are referred to in this study⁽¹⁵⁾. This balance facilitates the milk’s absorption, making it one of the reasons why the breastfed child is better fed than those whose mothers use formula milk.

Specialists on the subject highlight the value (also reflected in the nurses’ responses) of the safety that breast milk provides for the mother and baby⁽¹⁴⁾. As professionals working in maternal and child health, we reaffirm the value attributed to breastfeeding; however, we must emphasize that valuation is a specific process that involves a fact in a given space of time. Therefore, if breastfeeding has nutritional value for a baby's health, the value of food safety, emphasized by the nurses to the mothers, is presented with authority, since the search for health is and will always be regarded as a higher value.

Breastfeeding is a natural act, and scientifically proven to have many advantages for the baby. Knowledge about its nutritional value has been passed down to women from generation to generation, sharpening their perception on the subject. the nurses implied that they had no intention that their comments should be an accurate representation of reality, but to ensure that this perception became permanent The nurses implied in their responses ⁽¹⁶⁾.

As stated previously, the value of breastfeeding is determined by the beliefs and values that women have in relation to the nutritional attributes of milk, which influence the attitude they take toward breastfeeding and their willingness to breastfeed. It is important to remember that information alone is not enough for women to succeed in breastfeeding, or become motivated to do it. Additionally, nursing mothers become involved in a multidimensional process that incorporates various facets of reality lived by them, mainly related to individual aspects such as perceptions and feelings about breastfeeding⁽¹⁷⁾, which will certainly influence decisions of whether to breastfeed, regardless of their judgment with respect to food safety provided by human milk⁽¹⁸⁾.

We can mention, for example, consciousness, since it is the source of what is determined in real life, that is, the way the individual presents himself (to society)⁽¹⁹⁾.

Thus, the experience of breastfeeding is perceived by women, not only as an action to ensure the nutrition of the newborn, established in a context focused in the interaction with their child, but also as a process that expands and is reflected in other interactions of their personal lives, making their perceptions undergo constant changes throughout the course of this experience⁽²⁰⁾.

Thus, it appears that, as health professionals qualified to work with mothers in the breastfeeding process, the nurses must consider all aspects such as personal, social and biological factors, and be able to reaffirm the intrinsic values of breastfeeding.

Professionals perceive the mother, baby and family as members of the breastfeeding process in all its breadth and comprehensiveness, adjusting their advice to the reality, when talking about the safety that breast milk provides to the baby, encouraging the mothers to breastfeed.

CONCLUSION

Nurses who work with pregnant, postpartum and breastfeeding women value breastfeeding as a healthcare practice. In this sense, they ensure their professional presence in health facilities where their personal and professional values emerge and influence the healthcare process, guided by the biological, cultural and social aspects of the phenomenon of breastfeeding. In this context, they establish values experienced in their daily lives in relation to breastfeeding, resulting from personal and collective knowledge and cultures that make up the praxis of care, starting to promote the benefits of breastfeeding for the mother, child and family.

In this perspective, the study indicates that nurses value women as individuals, whose culture must be respected and even rescued, making this the starting point for all initiatives of care to women, especially in relation to breastfeeding as recommended by current policies.

Breastfeeding must be experienced before the mother can fully understand its importance to herself or her baby, referring to the concrete and historical existence of the nursing mothers under the care of nurses in the breastfeeding rooms of health facilities. This allows us to infer that breastfeeding is a value in itself; and, as regards the bond between mother and baby, this bond is perceived as a path for successful breastfeeding.

In this sense, it is asserted that, in the official space dedicated to nursing care in the units under the title Breastfeeding Friendly Primary Care Initiative of the city of Rio de Janeiro, the responses of the nurses brought out the valorative dimension of guidance and clarification of breastfeeding toward nursing mothers, confirming the everyday expression of know-how in nursing and the possibility of breastfeeding success, not only because it is a value in itself, symbolizing protection and safety for the child, but also because it is a full phenomenon of undeniable and recognized social value.

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Received: 19/01/2013
Revised: 01/12/2013
Approved: 02/12/2013