UNIVERSITY RESEARCH TRAINING

The female imagery and its invisibility in exclusive breastfeeding: an exploratory study

Tássia Regine de Morais Alves¹, Francisco Arnoldo Nunes de Miranda², Glauber Weder dos Santos Silva², Jovanka Bittencourt Leite de Carvalho², Cecília Nogueira Valença², Rosangela Diniz Cavalcante¹

¹State University of Rio Grande do Norte
²Federal University of Rio Grande do Norte

ABSTRACT
Aim: To understand the importance and the difficulties faced by women when adhering to exclusive breastfeeding.
Method: This is an exploratory and descriptive study, using a qualitative approach, in which semi-structured interviews were conducted with 14 women. Data treatment occurred by means of the content analysis, in the form of a thematic analysis.
Results: Most women revealed knowing the importance and benefits of breastfeeding for being an important practice, since it provides good nourishment and aids the development of the child. The aspects that benefit breastfeeding women were made explicit; however, these were given less focus when compared to the aspects related to the baby's health.
Conclusion: We should point out the need to incorporate practices beyond the biological dimension, to understand the characteristics of each woman and to encourage self-care as an important issue for them.
Descriptors: Breastfeeding; Women's Health; Children's Health.

INTRODUCTION

Taking into account the characteristics of society, it can be said that motherhood is a cultural product, where gender relations are anchored in inequality and the hierarchy of care. Women are seen universally as the caretaker of children, thus emphasizing their intrinsic role of breast feeder as a mandatory process, to the detriment of the invisibility of pleasure and self-care as an important issue^(1,2).

It is known that breastfeeding is recommended worldwide as the best way to provide adequate nutrition for the healthy growth and development of the baby until six months of age; moreover, it is associated with reduced infant mortality⁽³⁾. Historically, it has been identified as the main source of nutrients for young children and is a resource and natural process. However, it is known that its occurrence and effectiveness can suffer from external factors, such as, on the one hand, cultural, religious, demographic and socioeconomic factors; on the other, negative previous experiences, or whether the mothers are primiparous, have low levels of education, or the fact that they are young and/or single⁽⁴⁾.

Given the benefits that breastfeeding provides the mother-child dyad, several strategies have been established in order to encourage breastfeeding to minimize infant mortality in the country. Among the measures that have been set out, there is the Programa Nacional de Incentivo ao Aleitamento Materno (PNIAM) (National Program for Breastfeeding Promotion), which became part of the Integrated Health Actions, which relativizes the intervention to the obstacle for failing to carry out exclusive breastfeeding, integrating campaigns and training professionals.

Thus, the United Nations Children's Fund (UNICEF), the Ministry of Health (MoH) and PNIAM have established protective actions for exclusive breastfeeding. Thus, Brazilian law protects breastfeeding by laws based on the recommendations of these bodies and other legal devices that support it: the Brazilian Constitution (1988); Workers Law Consolidation; Ordinance 2,051/2001 of the Ministry of Health; Resolutions No. 221 and 222 of 2002 of the National Health Surveillance Agency; and the Decree 1,061/1992 of the MoS.

Among the technologies inserted in the primary care work process that can facilitate the promotion of exclusive breastfeeding, the Home Visit (HV) is an important tool that allows the recognition of the reality of postpartum women and nursing mothers, because it establishes links with the user⁽⁵⁾ and comprises essential aspects of family dynamics in breastfeeding. However, despite these initiatives in Brazil and, in particular, in the city of Caicó, State of Rio Grande do Norte, a negative reality and unsatisfactory indexes can be observed with regard to adherence to exclusive breastfeeding in the first months of the child's life⁽⁶⁾.

Due to the foregoing and the recognized benefits that this practice provides, the question is: do women understand the importance of exclusive breastfeeding? What are the difficulties in adopting the practice of exclusive breastfeeding?

As to the relevance of this study and its contributions to nursing, it is reasonable to point out that the actions and the care process during prenatal and medical and nursing consultations is nurses’ responsibility. Thus, we can admit that there is complexity in the act of breastfeeding, besides the approximation of reality, while recognizing the difficulties for the realization of exclusive breastfeeding, which indicates an educational practice capable of instilling confidence in the procedure and motivating the adoption and promotion of this habit.

We agree that study gaps exist in this area of knowledge to investigate the difficulties that women face in adhering to exclusive breastfeeding, in addition to recommendations to increase the scientific production to raise this issue⁽¹⁾. The aim is also to raise subsidies for reflection and guidance of the practices of health professionals, especially nurses, regarding the actions targeting the problem and to think about possible solutions to minimize the prevalence of non-exclusive breastfeeding.

This article aims to understand the importance and the difficulties that women face in adhering to exclusive breastfeeding, regarding the introductory summarization of this problem.

METHODS

This was an exploratory and descriptive study using a qualitative approach. The qualitative approach answers very specific questions, such as, the universe of meanings, reasons, aspirations, beliefs, values, and attitudes⁽⁷⁾.The survey was conducted in four areas covered by the Family Health Strategy (FHS) in the city of Caicó, located in the micro region of Seridó on the western region of the State of Rio Grande do Norte, Brazil. It was conducted to present the low rates of exclusive breastfeeding (<50%) for the period January-April 2012, according to information in the information System of Primary Care⁽⁶⁾.

The study population was made up of 14 women who were registered in the four areas defined for the research through the following listed criteria for inclusion of participants: living in urban areas of FHS coverage, not to be breastfeeding or not to be breastfeeding exclusively between the first and fourth months of postpartum and have performed prenatal care with nurses with the municipal FHS. The exclusion criteria were minors under 18 years old. The data collection took place between January and March 2013, through a semi-structured interview, recorded on an electronic device (MP4), and carried out during home visits after reading and signing the Consent Form. Data collection was performed in accordance with Resolution No. 466, December 2012, of the National Health Council (CNS). The study was approved by the Ethics Research Committee of the State University of Rio Grande do Norte and was approved according to CAAE No 03932312.1.0000.5294.

The interview data was analyzed from the content analysis (CA), in the form of thematic analysis for the identification of the core meanings, which allowed bringing meaning to the expected objects from the three complementary phases: pre-analysis, the exploitation of the material and treatment of results that included interpretation and inference⁽⁷⁾.

It is emphasized that this article is an excerpt of the research project entitled ‘Difficulties encountered by women regarding adherence to exclusive breastfeeding’, which was provided with a scholarship funding by the Institutional Scholarship Program for Scientific Initiation of the State University of Rio Grande do Norte. Given the ethical principles and to maintain the privacy of the research participants during the presentation of the results, we used the codes (M1 to M14) to identify the subjects.

RESULTS

Among the study participants, the predominant characteristics were low educational levels, family income between one and two minimum wages, being in the housekeeping profession or unemployed, aged between 25 and 29 years old and single. Given the content analysis, the following category was featured:

Female imagery regarding breastfeeding
Breastfeeding provides not only all the nutritional needs of the child in the first months of life, but also beneficial interactions for both mother and child, due to the physical contact between them. This physical contact will constitute the basis of the appropriate conception of the child's world⁽⁸⁾.
The statements revealed that physical contact with the child is something pleasurable for women, as it enables the strengthening of bonding:
]There is this issue of the bond with the mother, mother and child. (M13)

It is a natural food, suitable for the baby. There is also this issue of the affection between the mother, right, and the baby. (M14)

Knowledge related to the protection against diseases is shown in the following statements:
It is a natural vaccine, right? She rids the baby of various diseases and provides antibodies, not to mention the benefits to the body itself... (M2)

The properties of breast milk are good for the child's immunological system [...] it works as a vaccine that protects children from diseases, such as infections and allergies. (M4)

It works as a vaccine, the nurse explained. It really immunizes the baby. (M10)

Regarding the importance of breastfeeding, there is recognition in terms of its nutritional value:
] but I know that it is a source of vitamins; it’s very rich for the baby. (M9)

I know it's good because of the nutrition, you know? I know that breast milk nourishes the baby, right? It is a complete food; it's rich... (M3)

The mothers considered understanding the nutritional benefits for the child as relevant information. However, they had little knowledge and were uncertain in terms of the benefits provided by exclusive breastfeeding for the mother's health:
] I know it's good for growth, you know? The child grows healthy, but I don't know if there are benefits for me; only for the child, I think. (M5)

I haven't been informed about the breastfeeding benefits for the mother. But what matters is his health, right? (M7)

It is known that breastfeeding not only benefits the mother or the child, but the mother-child dyad in a unique and positive way. Below, the benefits that breastfeeding provides to maternal health are detailed, as perceived by the study participants:
The benefits for the mother is the fact that she loses weight faster; there is also the blood renewal issue; it improves the woman's immunological system, and also prevents breast cancer; I remember those. But I always read a lot about breastfeeding. (M7)

For me, I know it prevents breast cancer and uterine cancer. (M10)

In addition to the biological protection factors mentioned, other benefits provided by breastfeeding also include the practicality and exemption from the cost of breast milk substitutes:
For the mother it is also important, right? I've read it prevents bleeding after childbirth and breast cancer. Not to mention the economy, as you don't have to buy it or put it on the stove. It is always ready. (M8)

I give cow's milk to him, he likes it more. So I spend a lot. I know that, if he just suckled, I would save a lot of money. (M14)

The knowledge gained regarding the benefits of breastfeeding for the child's health was obtained through educational activities. Participants knew the importance of breastfeeding for the strengthening of the oral cavity of the infant, as stated below:
I've been to a conference on breastfeeding that took place in the school and I learned that it is good for the teeth. (M5).

The baby hardly gets sick when it is breastfed. It is especially good for the teeth, to have healthy teeth, it is very good [...] (M6)

Breastfeeding can also collaborate with better family life quality, as the child does not get sick so often:
It's great because he really doesn't get sick very often, so everyone is relaxed here at home. The whole family relaxes. (M1)

It's very good for child and the mother as well, [...] and the child falls sick less, and so it is good for the child and the family because it is healthy. (M9)

Other important aspects, such as the satisfaction and fulfillment of women when breastfeeding the child, were mentioned:
We feel good about being able to breastfeed the child. It is a sensation that I can’t even describe. (M10)

Contributing to the elucidation of the theme, the idealization and encouragement of breastfeeding by the media are evident, as mentioned below:
I see many incentives to simply breastfeed children on TV. (M1)

I know breastfeeding is good. On television there is much encouragement for mothers to breastfeed, right?! (M11)

The trivialization of the mothers' feelings, the lack of information in terms of the possible complications on the part of health professionals who assist these mothers and the evaluative mediatic stimulus can be factors for abandoning and discouraging breastfeeding:
The nurse said I was always supposed to breastfeed, but she has never said that problems could appear. It was as if, even with all this suffering, I still had to give the breast, but I couldn't stand it; it was too much pain. But I think she had to tell me the truth, because on television, all these things are very beautiful; but they should say that problems could be caused during breastfeeding, because they only speak good things. (M12)

In soap operas they always show women breastfeeding very happily. So the people just say that we have to breastfeed. But there are problems that appeared in the breast; and yet, they found a way of healing the breast so I could breastfeed again, even without the necessary conditions. (M6)

DISCUSSION

In a consensual manner, breastfeeding capabilities that go beyond the supplying of all the nutritional requirements of infants during the first months of life are attributed, by anatomical and physiological evidence, as they provide the physical contact between mother and child, beneficial interactions for both, for a subjectivity that will be the basis of the appropriate design of a child's world⁽⁸⁾.

In this sense, lactation is complex and involves the knowledge of women on this practice, which is permeated by biomedical and cultural concepts, values, beliefs, previous experiences and influences of family, society and health professionals⁽⁹⁾.

Failure to adhere to the practice of breastfeeding may be related to the lack of knowledge of mothers regarding its importance, or may be linked to a cultural, religious, ethnic, or economic trait to which they belong. Thus, taking into account the multidimensionality of the issue, it is pertinent to understand that these women are able to establish and maintain breastfeeding. It requires an approach that should start even prenatally, extending to the postpartum period⁽¹⁰⁾.

With regard to the meaning attributed by women to breastfeeding, it is commonly assigned as an important disease protection mechanism.

It has been agreed that children under six months who are not breastfed are at higher risk of not having their nutritional needs met and it may bring about increased neonatal mortality by 20%.

Also, non-breastfed babies have four times more chance of mortality from respiratory diseases; therefore, they present higher rates of hospital admissions. That said, morbidity and mortality could be prevented by adherence to exclusive breastfeeding⁽¹¹⁾.

Breastfeeding protects against respiratory infections, and this protection is greater when this practice is exclusive in the first six months of life. In addition, episodes of respiratory infections decrease and, therefore, there is less chance of hospitalization⁽⁸⁾.

It is perceivable, in the speeches analyzed in the categorical axis, that the nutritional value and immunological protection are benefits that deserve emphasis by the participants in this study by making an analogy between breast milk and vaccines. It is noteworthy that breast milk has all the nutrients that are essential for infant development and growth, in addition to being easy to digest when compared to milk from other species; it is able to meet the nutritional needs of children under six months of age, and remains an important source of food nutrients until two years of age, since it is rich in vitamins, proteins and fats⁽⁸⁾.

It is observed that the motivation for breastfeeding has been focused on the health benefits for the child - in other words, the baby is the reason for breastfeeding. This demonstrates the lack of value given to breastfeeding for maternal health: it is believed that the mother needs to feel stimulated to carry out this practice satisfactorily. Given the above, the advantages of breastfeeding are fully dedicated to children, leaving mothers aside. Protagonists of this process believe that it is understood that women also need to feel valued and motivated to carry out such a practice.

The strictly biological moments of motherhood, pregnancy, childbirth and breastfeeding profoundly shape the relationship of women to health and, ultimately, with medicine and nursing. That is because these moments are usually medicalized; furthermore they imply that it is the responsibility of the woman for the good health of the child. This responsibility is extended throughout the period in which the child depends on the mother, who often persists on it until the adulthood of her child⁽²⁾.

Women are, to some extent, retransmitting agents of medical institutional knowledge concerning their own bodies, without taking part in the production of this knowledge. Additionally, they are subject to a medical hierarchy that is based on a conception of the "feminine nature": a sensitive, patient and devoted figure that is always able to care for others. One of these representations is related to health, as women end up being the main person responsible for the health of their children, since they are biological mothers⁽²⁾.

Breastfeeding is understood to be an important and appropriate practice for the child regarding the health-disease process. In addition, the knowledge related to breastfeeding was acquired through lectures. The prenatal period is a time of physical and psychological preparation for childbirth and motherhood, a time of intense learning, and an opportunity for the health team professionals to develop education as a dimension of the care process⁽¹²⁾.

From this perspective, health education is a set of knowledge and practices, which are used as guides for disease prevention and health promotion. It is a resource through which knowledge, which has been scientifically produced in the health field, reaches the everyday life of people, since the conditioning factors of the health-disease process offer support for adopting new habits and behaviors⁽¹³⁾.

It is believed that educational activities make a positive impact on life quality. An effective strategy concerns the group of pregnant women, in order to strengthen breastfeeding practices and promote the autonomy of these women. This moment must be valued especially by health professionals, since it is an invaluable tool for the expansion of knowledge, in which mothers can exchange experiences and clarify various doubts⁽¹⁴⁾.

A theme that can be worked on during educational activities highlights the importance of breastfeeding for a healthy dentition development. The reports revealed that the participating women recognized breastfeeding as an important practice for the development and strengthening of teeth.

Arguably, alimentation is an important and proper exercise for the oral cavity of the infant, since it provides a better conformation of the hard palate, which is essential for the correct alignment of the teeth and good dental occlusion. Failure to adhere to the practice of breastfeeding may lead to a disruption in proper oral motor development and can affect the functions of chewing, swallowing, breathing and articulation of speech sounds, among others⁽⁸⁾.

Breastfeeding is the best way to provide food for the growth and proper development of the baby, as well as being an integral part of the reproductive process, with a positive impact on maternal health⁽¹⁵⁾.

Currently, it has been proved that the practice of breastfeeding also provides benefits for maternal health, because, as it starts in the first hour after birth, there is a stimulus for the production of oxytocin, which prevents bleeding in the post delivery period, in addition to stimulating uterine involution, thus minimizing the risk of anemia; it also strengthens the mother-child bond⁽¹⁶⁾.

For decades, the arguments in favor of breastfeeding were focused on the benefits that this practice provides to children's health. Later, the benefits that breastfeeding provides maternal health were emphasized⁽¹⁷⁾.

Breast cancer prevention and decreased postpartum bleeding are aspects that made up the speeches. In addition, the factor of economics and practicality of the breast milk was mentioned. The practice of breastfeeding associated with a reduction in cancer rates is already well established. It is estimated that the probability of contracting the disease decreases by 4.3% for every 12 months of lactation. This protection is independent of age, ethnicity, parity, and presence or absence of menopausal symptoms⁽⁸⁾.

Breastfeeding can reduce the chances of developing breast cancer because this condition induces the maturation of the mammary glands, making the cells more "stable", and less susceptible to the appearance of cancer. This statement is based on the assumption that women are less exposed to estrogen hormones during breastfeeding because there is an increased prolactin and oxytocin with the handling of the placenta, which is responsible for lactopoiesis, and its high levels inhibit estrogen. Because breast cancer is a hormone-dependent disease to estrogen, breastfeeding becomes a protective factor for this disease⁽¹⁷⁾.

It is known that the benefits of breastfeeding for women's health are poorly addressed during prenatal consultations. Usually, the information is geared to the child's health, although it is recognized that, for women, breastfeeding has important advantages. Thus, it is critical that health professionals value the importance of the mothers' role in promoting breastfeeding. It is believed that guidelines throughout pregnancy and childbirth are indispensable in order to adequately inform women in terms of the importance of this issue for protection against breast cancer.

It is understood that the female world is permeated by many factors that are not always considered during professional performance and that the technical and academic information that supports this practice have been targeted to the needs of the child, and have not included the particular qualities of women⁽¹⁸⁾.

Breastfeeding can improve the quality of life of families, since children who are breastfed suffer less sickness, require less medical care, hospitalization and medication and, therefore, parents have greater assiduity at work, reduced expenses, and less stressful situations, thus improving the quality of life for their families⁽⁸⁾.

The bond between the mother and child in the pleasurable breastfeeding process presents a unique moment that provides intimate contact, thereby increasing the bonds of affection and love between them. Thus, the value of that moment and the intrinsic relationship that the act of breastfeeding provides between the binomials brings moments of interaction, making breastfeeding pleasurable, and not mandatory⁽¹⁹⁾.

In this sense, it is worth emphasizing the importance of prenatal care for both maternal and children’s health. It is essential to prepare and provide support for future mothers with the promotion of breastfeeding, as well as the benefits that such practice provides for the mother and child. It is the opportune time to carry out the promotion of breastfeeding, and it is up to the professionals to encourage women to breastfeed. During prenatal monitoring, the guidance received by pregnant women increases their knowledge in terms of breastfeeding and, therefore, the prevalence of this social practice, especially if it is performed by a trained professional⁽⁹⁾.

Currently, strategies to promote breastfeeding are still structured in a biologist and reductionist model, which is unable to cope with the subjectivity of women between the desire and the ability to breastfeed⁽¹⁸⁾. By exploring the potentials and weaknesses of breastfeeding, professionals can concentrate their actions in mechanistic interventions, based on the obligatory breastfeeding beyond the reality of women. It is also known that in society, the incentive is widespread in the media, especially by the media coverage of the benefits generated by exclusive breastfeeding.

Lactation is inserted in a historical, socio-cultural and psychological context, so that this process represents different meanings for each society and for each woman. In this context, nursing mothers are held accountable and, at the same time, are excluded from the act of breastfeeding as women. At times they are active subjects, because they have the responsibility to breastfeed; at other times they are passive because their feelings and desires are not taken into account in this process⁽¹⁸⁾.

The dissemination of the benefits of breastfeeding has been a universal strategy in the scientific community and widespread in the mass media. Thus, another aspect present in the information was the idealization made by the media, extolling the practice that appears to be without difficulties. In this study, however, women showed their frustration with the experience of an imperfect reality, which is often fraught with difficulties and, above all, is far from the idealization passed on by the media, which portrays breastfeeding as a generative practice of happiness and pleasure. The lack of sensitivity on the part of some health professionals is noticeable, when they are faced with the pain of women who are trying to breastfeed. This vertical and reductionist approach does not allow for the necessary support to women and is configured as one of the discouraging breastfeeding factors.

Most women idealize breastfeeding as a natural process; however, they believe they will not face any difficulties. Nevertheless, in order to develop breastfeeding skills with the expected degree of success, it is necessary to receive a variety of information. The efforts of health professionals need to be targeted to facilitate this process of apprenticeship and adaptation of women in this new maternal role, as there is insensitivity of health professionals, or even of the family, concerning the pain of women when trying to breastfeed. This may be a factor that arouses feelings of loneliness and isolation, resulting on breastfeeding abandonment on the part of many women who have been unsuccessful in getting their babies to feed naturally⁽²⁰⁾.

CONCLUSION

The study participants revealed that they recognized the importance of exclusive breastfeeding by emphasizing the good conditions for the development of the child, both in the nutritional and immunological values and the increased bonding of affective relations between mother and child. Aspects related to breastfeeding women benefits were less revealed when compared to related aspects. For example, the dichotomy between mother and child: on one hand the baby/child and the centrality of health promotion and prevention and the production of senses for both; on the other, the invisibility of the mother as a participant of the advantages of this act of human life.

The influences of the media and nurses during prenatal visits were mentioned as valuable factors, but were little enlightening in terms of the effects for the mother. However, we reported the difficulties in breastfeeding were exclusively due to breastfeeding complications; furthermore, guidelines on this possibility are not mentioned or clarified in consultations, revealing weaknesses in overcoming obstacles and the mothers being deemed responsible for not continuing to breastfeed.

We recognize that there is a gap in the study in terms of the number of subjects studied, and the results are closely related to socio-psychosocial conditions, therefpre, making it possible to find other realities in different dimensions. However, it does not make it less relevant, as it brings the mother's invisibility in the dyad proposed by the ministerial recommendations on exclusive breastfeeding, understanding that the meanings attributed to this process interfere with its effectiveness.

Studies based on this approach should be encouraged, since the dimensions that can hinder breastfeeding will be apprehended, outlining a new path so that nursing can act in a way that is more empathetic and be directed to the specific needs of each woman.

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All authors took part in the phases of this publication in one or more of the following steps, according to the recommendations of the International Committee of Medical Journal Editors (ICMJE, 2013): (a) substantial participation in the planning or preparation of the manuscript or the collection, analysis or interpretation of data; (b) preparation of the job or performance of critical review of the intellectual content; (c) approval of the submitted version. All authors declare, for any purpose, the content related to all aspects of the manuscript submitted to OBJN is their responsibility. They ensure that the issues related to the accuracy or completeness of any part of the article have been properly investigated and resolved, exempting thus the OBJN of any joint participation in any imbroglios on the matter at hand. All authors declare that they have no conflict of interest, whether financial or relationship, to influence the drafting and/or interpretation of the findings. This statement has been digitally signed by all authors as recommended by the ICMJE, whose model is available at http: // www. objnursing.uff.br/normas/DUDE_final_13-06-2013.pdf

Received: 06/01/2015
Revised: 04/05/2016
Approved: 04/05/2016