hearing retest within 30 days of life, with their mothers, and ... rupt exclusive breastfeeding within the first month of life of ... generally offered in a cup (93.8%).
Original Article
Factors associated with the interruption of exclusive breastfeeding in infants up to 30 days old Fatores associados à interrupção do aleitamento materno exclusivo em lactentes com até 30 dias
Revista Gaúcha de Enfermagem
Factores asociados a interrupción de la lactancia materna exclusiva en lactantes con hasta 30 días
Bruna Alibio Moraesa Annelise de Carvalho Gonçalvesb Juliana Karine Rodrigues Stradac Helga Geremias Gouveiab
How to cite this article: Moraes BA, Gonçalves AC, Strada JKR, Gouveia HG. Factors associated with the interruption of exclusive breastfeeding in infants up to 30 days old. Rev Gaúcha Enferm. 2016;37(spe):e2016-0044. doi: http://dx.doi.org/10.1590/19831447.2016.esp.2016-0044.
doi: http://dx.doi.org/10.1590/19831447.2016.esp.2016-0044
ABSTRACT Objective: To identify factors associated with the interruption of exclusive breastfeeding (EBF) in infants up to 30 days old. Method: A cross-sectional study conducted at a university hospital in southern Brazil, from December 2014 to September 2015, with 341 infants up to 30 days old and their mothers. A semi-structured questionnaire was applied consisting of variables related to sociodemographic characteristics, obstetric history of the mother, companion’s education, and data of the infant and of breastfeeding. Collected data were subjected to bivariate and multivariate analysis with the estimation of Prevalence Ratios (PR). Results: The prevalence of EBF was 79.5%. The factors associated with the interruption of EBF were babies ≥ 21 days, who received formula supplementation at the hospital, women with difficulties breastfeeding after hospital discharge, and non-white. Conclusion: the factors associated with EBF interruption can help health workers create actions for mothers with difficulties and prevent interruption of EBF. Keywords: Breastfeeding. Weaning. Prevalence. RESUMO Objetivo: Identificar fatores associados à interrupção do aleitamento materno exclusivo (AME) em lactentes com até 30 dias de vida. Método: Estudo transversal realizado em hospital universitário do Sul do país, de dezembro de 2014 a setembro de 2015, com 341 lactentes com até 30 dias de vida e suas mães. Aplicou-se questionário estruturado composto por variáveis relativas às características sociodemográficas e história obstétrica da mãe, escolaridade do companheiro, dados do lactente e da amamentação. Procedeu-se análise bivariada e multivariada, como cálculo de Razão de Prevalências (RP). Resultados: Prevalência de 79,5% de AME. Lactentes ≥ 21 dias, que receberam complemento lácteo no hospital, mães com dificuldade de amamentação pós-alta hospitalar e não-brancas apresentaram associação à interrupção do AME. Conclusão: Os fatores associados à interrupção do AME direcionam os profissionais de saúde a proporem ações de apoio à mãe e lactente em vista de suas dificuldades, prevenindo a interrupção do AME. Palavras chave: Aleitamento materno. Desmame. Prevalência.
Universidade Federal do Rio Grande do Sul (UFRGS), Escola de Enfermagem, Programa de Pós-graduação em Enfermagem. Porto Alegre, Rio Grande do Sul, Brasil. a
Universidade Federal do Rio Grande do Sul (UFRGS), Escola de Enfermagem, Departamento de Enfermagem Materno-Infantil. Porto Alegre, Rio Grande do Sul, Brasil. b
Universidade Federal do Rio Grande do Sul (UFRGS), Escola de Enfermagem, Porto Alegre, Rio Grande do Sul, Brasil. c
RESUMEN Objetivo: Identificar factores asociados a la interrupción de la lactancia materna exclusiva (LME) en lactantes con hasta 30 días de vida. Método: Estudio transversal realizado en un hospital universitario al sur de Brasil, de diciembre de 2014 a septiembre de 2015, con 341 lactantes de hasta 30 días y sus madres. Se aplicó cuestionario estructurado compuesto por variables de características sociodemográficas y la historia obstétrica materna, educación del compañero, datos infantiles y lactancia materna. Se procedió al análisis bivariado y multivariado, con cálculo de Razón de Prevalencia (RP). Resultados: Prevalencia del 79,5% de LME. Lactantes ≥21 días de vida, que recibieron complemento lácteo en hospital, mujeres con dificultad para amamantar después del alta y las no blancas se asocian a la interrupción de LME. Conclusión: Los factores asociados a la interrupción de LME direccionan a los profesionales para proponer acciones de apoyo a la madre y a su lactante delante de sus dificultades, impidiendo el destete precoz. Palabras clave: Lactancia materna. Destete. Prevalencia.
Online Version Portuguese/English: www.scielo.br/rgenf www.seer.ufrgs.br/revistagauchadeenfermagem
Rev Gaúcha Enferm. 2016;37(spe):e2016-0044
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Moraes BA, Gonçalves AC, Strada JKR, Gouveia HG
INTRODUCTION In recent decades, an increasing number of studies on breastfeeding has proven the benefits of this practice for the mother and infant. The expansion of breastfeeding at an almost universal level prevents an estimated 20,000 deaths per year from breast cancer and 823,000 deaths each year in children under five worldwide(1). The World Health Organization (WHO) recommends exclusive breastfeeding (EBF) for the first six months of the infant’s life, after which other foods should be introduced(2) to meet the nutritional needs of infants and ensure healthy growth and development(3). A higher intelligence quotient score, more years of schooling, and higher monthly income during adulthood are some of the benefits of infants breastfed for 12 months or more in comparison with infants who were breastfed for less than a month(4). The benefits for mothers include protection against breast and ovarian cancer and diabetes type 2(1). The first postpartum days are crucial for the future of breastfeeding. Mother who stay in a shared room and are 24 hours a day with the baby are more likely to breastfeed exclusively in the first month(5). Moreover, in-hospital guidance on breastfeeding supports the continuity of breastfeeding for the recommended period(6). To prolong breastfeeding, in light of its numerous benefits, primary care must provide critical support and follow-up for nursing mothers and their infants. Identifying the factors associated with the interruption of EBF and understanding the local realities can help improve measures for the promotion and protection of breastfeeding(7). Similarly, investigating the factors associated with the interruption of EBF provide health workers with insight into their practices related to breastfeeding and on the ideal strategies to encourage the continuity of exclusive breastfeeding. The hypothesis of this study is the existence of maternal and infant factors associated with the interruption of exclusive breastfeeding in infants up to 30 days old. The aim of this investigation is to identify the factors associated with the interruption of exclusive breastfeeding in infants up to 30 days old.
METHOD This present study is the result of the final work of the graduate nursing course titled, “Fatores associados à in Data provided by the institution
d
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Rev Gaúcha Enferm. 2016;37(spe):e2016-0044
terrupção do aleitamento materno exclusive em bebês com até 30 dias de vida”(8). It is a quantitative, observational, cross-sectional study. Research was conducted at the ambulatory unit of a large teaching hospital (HCPA) in southern Brazil, considered a reference for high-risk pregnancies, with an average of 300 deliveries/monthd, and a certified babyfriendly hospital since 1998. This hospital conducts a set of activities to promote, protect, and support breastfeeding. During hospitalization, the infant undergoes Newborn Hearing Screening, and the infants with any alteration in the test results are referred to the second retesting stage at the outpatient clinic of the hospital within 30 days after birth. Around 5% of the newborns who stay in the shared room with their mothers return to the retestd. At this time, the mothers were invited by the researchers to participate in the study. Research included the infants who returned to the hearing retest within 30 days of life, with their mothers, and who remained during the entire post-natal stay at the Obstetrics Admissions Unit (“UIO”). Infants for whom breastfeeding had been contraindicated were excluded. The sample size was determined using Epilnfo version 7. The sample was calculated using previous research in the same institution that related independent variables with the outcome of early weaning. We opted for the variable with the lowest relative risk (RR) to define a sample number that can be obtained in the study period. The RR for the outcome early weaning, when associated with the return of women to work, was 1.59(7). Therefore, the sample size was 341 infants and their mothers, considering a power of 80% and significance level of 5%. Data were collected from 22 December 2014 to 22 September 2015, through a structured questionnaire prepared by the researchers, applied to the mothers of infants who returned to the hearing retest. Ten questionnaires were previously tested with the studied population and adjusted accordingly. The interruption of EBF was the dependent variable, which is associated with the independent variables for sociodemographic characteristics, characteristics of the infant, the companion’s education, obstetric history, and breastfeeding history. The data were subjected to descriptive analysis. Pearson’s Chi-square test or Fisher’s exact test were applied to compare the proportions, depending on the percentage of cells with the expected number ≤ 5. The Poisson regression was used to control confounding factors. Multivariate analysis included the variables with a value of p ≤ 0.20 in
Factors associated with the interruption of exclusive breastfeeding in infants up to 30 days old bivariate analysis. The applied measure of effect was the Prevalence Ratio (PR) with a 95% confidence interval and a significance level of 5% (p ≤ 0.05). The analyses were conducted using SPSS software, version 18.0. The project was submitted and approved by the research commission of the Escola de Enfermagem da Universidade Federal do Rio Grande do Sul (#028382) and by the research ethics committee of the Hospital de Clínicas de Porto Alegre (HCPA) (#140681), as established by Brazilian law for human research. The patients who agreed to participate in the study signed an informed consent statement.
RESULTS In all, 341 infants aged up to 30 months and their mothers were included in the study. Of these infants, 20.5% were not exclusively breastfed and other food was supplementing or replacing breast milk. Table 1 shows the sociodemographic characteristics of the mothers, the characteristics of the infants, and the level of education of the companions. The variables with a statistical significance were mother’s skin colour, return to work, age of the infant, and education of the companion. The data shown in Table 2 refer to the obstetric history of the mothers. The statistically significant variables were number of prenatal consultations, the mother’s participation in prenatal groups, and type of current delivery. Table 3 shows the variables relating to breastfeeding. It is observed that most of the variables were statistically significant, except how the hospital supplement was received, intent to breastfeed after discharge, whether mother received help to breastfeed, and if mother is breastfeeding on free demand. The variables that reached a significance level ≤ 0.20 were inserted in the multivariate analysis presented in Table 4. The mothers who claimed to be non-white were more prone to interrupt breastfeeding (PR: 2.58; CI95% 1.18 to 5.62; p = 0.018). Those who had some difficulty breastfeeding after discharge were 2.64 times more likely to interrupt exclusive breastfeeding within the first month of life of the infant in comparison to the mothers who did not have difficulties after hospital discharge. In the variables related to the infant, the prevalence of interrupted breastfeeding in infants with 21 days or more was around four times greater than in infants with 20 days or less. The infants who were given formula and breast milk at the hospital were two times more likely to have interrupted breastfeeding that those who did not receive formula. The results show that during the hospital stay at the shared room, 23.5% of the infants received a supplement,
generally offered in a cup (93.8%). The most common justifications provided by the mothers was that the “infant could not suck” (35.0%) and hypoglycaemia (30.0%). As regards difficulties breastfeeding after hospital discharge, 44.7% of mothers reported some kind of difficulty, especially nipple fissure (64.1%).
DISCUSSION In the discussion, we will only focus on the variables that obtained a statistical significance after multivariate analysis or are somehow related to these variables. The prevalence of exclusive breastfeeding at the end of the first month of life of the infants in this study is considered “good” according to parameters established by the WHO(2). In a study(9) conducted previously at the same hospital, this rate was 54% when the institution was completing 10 years of certification as a baby-friendly hospital. The increase in exclusive breastfeeding rates may be a reflection of the constant work to promote and protect breastfeeding conducted by the workers at the institution, and the establishment of government programmes, like the Rede Cegonha (Stork Network) in 2011 and the Estratégia Amamenta e Alimenta Brasil (Strategy Breastfeed and Feed Brazil). Despite the increase in the percentage of EBF found in this study, a higher rate was found in a cohort study conducted in Bahia, which found 89.6% of infants being exclusively breastfed by the end of the first month of life(6). However, a very different reality is found nationwide, including in the same state in which this research was conducted. A prospective cohort study conducted in Pelotas/RS found that 60% of infants were exclusively breastfed in the first month, and around 10% had already been weaned(7). An even lower percentage was found in Jordan, South-East Asia, where only 37.8% of infants with 30 days of age were being exclusively breastfed, dropping to 6% in the fourth month of life of the infant(10). One of the factors found in this research associated with the interruption of EBF was skin colour. Self-proclaimed non-white mothers are more prone to stop exclusively breastfeeding their children than self-proclaimed white mothers. This finding is corroborated in other research(11), in which it was noted that white mothers were 20% more likely to exclusively breastfeed until the sixth month of life of the infant. A similar result was found in a study conducted in Campinas/SP; however, the focus was on the skin colour of the infant rather than the mother. It was observed that black/brown-skinned infants are breastfed for less time than white infants(12). Rev Gaúcha Enferm. 2016;37(spe):e2016-0044
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Moraes BA, Gonçalves AC, Strada JKR, Gouveia HG Table 1 –Bivariate analysis of the interruption of the EBF in infants up to 30 days old with the sociodemographic characteristics, characteristics of the infant, and schooling of the companion, HCPA, Porto Alegre (RS), 2015 Variables
n
Interruption of EBF within the 1st month n (%)
< 20
53
12 (22.6)
≥ 20
288
58 (20.1)
Mother’s age
0.678
Mother’s education
0.710
Finished primary school
101
22 (21.8)
Secondary school or more
240
48 (20.0)
Mother’s skin colour
0.084
White
199
34 (17.1)
Non-white
142
36 (25.4)
Marital status
0.499
With companion
315
66 (21.0)
Without companion
26
4 (15.4)
Paid occupation
0.995
Yes
185
38 (20.5)
No
156
32 (20.5)
Maternity leave
0.644
Yes
151
32 (21.2)
No
34
6 (17.6)
Return to work
0.043
Yes
14
6 (42.9)
No
171
32 (18.7)
Family income
0.725
Up to 2 minimum wages
93
17 (18.3)
2-4 minimum wages
167
37 (22.2)
More than 4 minimum wages
63
12 (19.0)
Infant’s age
0.136
Less than 10 days
31
4 (12.9)
10 - 20 days
264
52 (19.7)
More than 20 days
46
14 (30.4)
Newborn< 2500g
0.520
Yes
15
4 (26.7)
No
326
66 (20.2)
Newborn < 37 weeks
>0,999
Yes
18
3 (16.7)
No
322
67 (20.8)
Companion’s education
4
0.157
Finished primary school
104
26 (25.0)
Finished secondary school or more
199
36 (18.1)
Source: Research data, 2015. * Pearson’s Chi-square Test or Fisher’s exact test
Rev Gaúcha Enferm. 2016;37(spe):e2016-0044
p*
Factors associated with the interruption of exclusive breastfeeding in infants up to 30 days old Table 2 –Bivariate analysis of the interruption of EBF in infants up to 30 days old with the obstetric history, HCPA, Porto Alegre (RS), 2015 Variables
Interruption of EBF within the 1st month n (%)
n
First pregnancy
0.526
Yes
159
35 (22.0)
No
182
35 (19.2)
Prenatal care
0.205
Yes
340
69 (20.3)
No
1
1 (100.0)
Number of prenatal consultations
0.118
