Mothers ’ perception of nurses ’ breastfeeding promotion practices

Theoretical framework: The success of breastfeeding depends on the mother’s historical, sociocultural, and psychological factors, as well as on the health professionals’ commitment, and technical and scientific knowledge to promote and support breastfeeding. Objectives: To identify mothers’ perception of nurses’ breastfeeding promotion practices. Methodology: A quantitative descriptive correlational study was conducted in a nonprobability purposive sample of 88 mothers of children aged between 2 days and 3 years. A questionnaire was applied during May 2012. Results: Nurses’ practices were considered as fair and poor by 43.2% and 29.5% of the mothers, respectively. Education, the workplace, and the working time are associated with the mothers’ perception of nurses’ breastfeeding promotion practices. Conclusion: Nurses should reflect on their breastfeeding practices and training, encouraging mothers not only from a normative and technical perspective, but also from a psychosocial perspective, adapting their practices to each woman’s needs.


Introduction
The fact that almost all women are physiologically able to breastfeed is not a guarantee of breastfeeding. On the other hand, the fact that women are aware of the advantages and benefits of breastfeeding is not also a guarantee of a successful breastfeeding experience. The decision to breastfeed is associated with complex social, economic, psychological, and cultural factors that influence individual and community behaviours (Kronborg, Vaeth, Olsen, Iversen, & Harder, 2007). Healthcare professionals' breastfeeding promotion interventions are reflected in breastfeeding rates and duration, which increase when women receive breastfeeding counselling (Andrade et al., 2009). A breastfeeding promotion programme should use standardised information and guidelines and be available from the prenatal to the postnatal period and throughout the breastfeeding period. The programme should educate women about the benefits of breastfeeding and provide appropriate guidance on preventing and solving the main problems that may occur during the breastfeeding process (Parizotto & Zorzi, 2008). Nurses must be aware of the breastfeeding benefits for the child and the mother, the economic advantages, the impact on the reduction of parents' absenteeism and the current breastfeeding guidelines to focus their attention on breastfeeding promotion (World Health Organization, 2009). They should also recognise the factors that may positively or negatively influence the success of breastfeeding, as well as understand the reasons leading to an early introduction of other liquids/solid food in the infant's diet. Some of these factors relate to the mother, her personality, and her attitude towards the decision to breastfeed, whereas others relate to the child and the environment, such as the circumstances of birth and the postnatal period. Another factor is the mothers' employment, as the non-formal integration into the job market keeps them from enjoying legal benefits such as maternity leave. The nurse must be able to create a favourable environment for breastfeeding, establishing a relationship of trust and support for this practice to be effectively implemented. It is also important to identify women as key to the breastfeeding process, valuing the way in which each woman experiences this significant moment, so that they are able to choose according to their real desires and regardless of social pressures (Cunha, Santos, & Gonçalves, 2012). Healthcare professionals' interventions often focus on the evidence-based biological and emotional benefits for the child, neglecting the psychosocial dimensions (Bassichetto & Réa, 2008). Only a valid, continuous, and renewed knowledge on this topic and the social and cultural factors of the surrounding community will allow for the implementation of formative and informative programmes and practices adapted to each woman' needs, with concrete and effective measures to promote, protect, and support this practice. A study was conducted with the following objectives: To identify the mothers' perception of the nurses' breastfeeding promotion practices; To analyse the association between the mothers' sociodemographic variables and their perception of the nurses' breastfeeding promotion practices; To verify if the mothers' motivation towards breastfeeding influences their perception of the nurses' breastfeeding promotion practices; To determine the influence of the previous breastfeeding experience on their perception of the nurses' breastfeeding promotion practices. The purpose of this study is to contribute to a reflection on this practice, thereby improving the nurses' breastfeeding promotion practices.

Breastfeeding promotion, protection, and support: concepts and initiatives
In recent years, a major investment has been made in important initiatives to promote breastfeeding both due to its benefits and its impact on public health. Hence, the concepts of breastfeeding promotion, protection, and support have become important to understand these initiatives. Promotion aims to create cultural values and behaviours favourable to breastfeeding based on the recommendations of health and social services and national policies so that it can be taken as a norm (Pinto, 2008). On the other hand, protection allows for the establishment and enforcement of a set of laws which allow women to enjoy their right to breastfeed. Support consists of advising and conveying valid information at the correct time. It also requires friendly Hospitals. Eleven Portuguese hospitals are currently certified by the WHO/UNICEF as Babyfriendly Hospitals (UNICEF, Fundo das Nações Unidas para a Infância, 2014). Several breastfeeding promotion initiatives have been promoted by the WHO/UNICEF, such as training courses for breastfeeding counsellors and international conferences, thus enabling a progressive change in the services' and the professionals' practices.

Research questions
The following research questions guided this study: What is the mothers' perception of the nurses' breastfeeding promotion practices?; To what extent are the mothers' sociodemographic variables (age, marital status, area of residence, employment situation, and academic qualifications) associated with their perception of the nurses' breastfeeding promotion practices?; To what extent do the previous breastfeeding experiences and the motivation towards breastfeeding influence the mothers' perception of the nurses' breastfeeding promotion practices?

Methodology
Taking into account our concerns, a quantitative descriptive correlational study was conducted. A selfadministered questionnaire was used which had been built based on an instrument developed by Silvestre, Carvalhaes, Venâncio, Tonete, & Parada (2009) and adapted by the authors to meet the study objectives. The questionnaire was composed of several questions on sociodemographic and obstetric aspects and experience of breastfeeding and others related to the mothers' perception of the nurses' breastfeeding promotion practices. Promotion practices were divided into four dimensions: Breastfeeding encouragement; Breastfeeding Counselling; Breastfeeding protection/ support; Trust/Communication between the mother and the nurse. Each one of these dimensions included several questions and was rated based on the recommendations of the Observatório do Aleitamento Materno (Breastfeeding Observatory) (Direção Geral de Saúde, 2012). Right answers scored 1 (one) and wrong answers scored 0 (zero). The sum of the partial scores of the dimensions resulted in commitment and social mobilisation in order to restore standards of good practice at the institutions (Pinto, 2008). Breastfeeding promotion strategies must include technical information related to the biological aspects of lactation, but imply understanding that the final decision will be made by the woman/couple and that it is involved in some subjective issues. Although breastfeeding benefits are already known since the 1980s, still today the UNICEF refers that the percentage of exclusively breastfed infants for the first six months and supplemented with other foods up to two years or more is below 50% (WHO, 2009). Portuguese studies indicate a high incidence of breastfeeding at discharge from the maternity hospital (67-100%) but a rapid decline during the first month of life (35-83%), with 17 to 35% of infants being exclusively breastfed at six months (Brito, Alexandrino, Godinho, & Santos, 2011). Portuguese data fall within the range found in southern European countries, with breastfeeding initiation rates higher than 90%, decreasing to less than 25% at six months (WHO, 2009). In 1990, the WHO and UNICEF joined together to produce the Innocenti Declaration, where breastfeeding was recognised as a unique process that contributed to the health of the child and the mother and provided economic benefits to the family and the nation. In 1991, following the World Summit for Children, the same institutions launched the global programme for breastfeeding promotion -Baby-friendly Hospital Initiative. The main purpose of this programme is to promote, protect, and support breastfeeding in healthcare settings, through the consistent and sustained implementation of breastfeeding support measures (WHO, 2009). Since 1989, several projects have been designed and developed in Europe with the support of the European Union with the aim of promoting the development and implementation of action plans for breastfeeding promotion. Although Portugal has adopted and adhered to all breastfeeding promotion initiatives and participated in international work, breastfeeding rates remain low and the attention given to this issue is not always the best (Lourenço, 2009). Since 1992, Portugal has gathered efforts to achieve the levels of quality required by the WHO/UNICEF to become part of the international network of Baby-the overall score of nurses' breastfeeding promotion practices which ranged between a minimum score of 0 (zero) and a maximum of 14 (fourteen). Extreme cutoff points were established using the formula of mean ± 0.25 standard deviation, and the breastfeeding promotion practices were classified as Poor (<7), Fair (7-9), and Good (>9). SPSS Version 21.0 for Windows was used, and the significance level was set at 5% (p=0.05). The Mann-Whitney U-test, Kruskal-Wallis Test, and Spearman's rank correlation were used. A nonprobability purposive sample was used consisting of 88 mothers of children aged between 2 days and 3 years. As it is a retrospective study, the questions on the mothers' experiences of breastfeeding practices reported not only to the period after birth, but also during pregnancy. The study was conducted during the month of May 2012 in Obstetric, Paediatric I, Paediatric Emergency and NICU units of a hospital centre of central Portugal, after permission was granted by the Ethics Committee.

Results
The mothers' mean age was 31.10 years (±5.22), 80.5% were living with a partner, 42.1% had secondary education, and 48.9% lived in an urban area. At the professional level, most women worked (78.4%), most of them worked in the tertiary sector (65.6%) and most of them worked full-time outside the home (68.8%). Most of them had only one child (69.3%) aged between 0-6 months (35.4%). Most mothers were not breastfeeding their child (52.3%), having breastfed on average for 181.42 days. We found that 96.0% of them had breastfed all of their children (59.1% and 71.4% during 0-6 months in the 1 st child and 2 nd child, respectively). Those who did not breastfed reported having had problems with the milk (42.9%). It was found that 86.4% of the mothers feel or felt very motivated to breastfeed, justifying their answer with the benefits of breastfeeding (68.2%). The decision to breastfeed was taken by the mother (93.8%), and 77.9% of them had already made that decision before becoming pregnant. The decision of not to breastfeed was made by the mothers in 57.1% of cases. Most of them took this decision after birth (83.3%), with the most common reason being insufficient milk (78.4%).
Moreover, most mothers reported having received training or information on breastfeeding (86%). They received information during pregnancy (52.9%) or the postnatal period (37.6%). According to them, the nurse was the professional who provided more training or information (91.8%). Table 1 shows the various dimensions of the dependent variable 'breastfeeding promotion practices'. As regards 'encouragement', most mothers (65.6%) reported having been informed that they should breastfeed whenever the baby shows signs of hunger. The mothers reported that, in most cases (43.7%), they were advised against using a pacifier until breastfeeding was well established, and 32.2% of them reported that they were never or rarely advised against using it. In this study, the most recommended measure for breast engorgement in the first few days was the use of a breast pump to express milk (40.4%), followed by the application of moist heat (31.7%). It should be underlined that no mother had been advised to suspend breastfeeding. In relation to the technical aspects of breastfeeding, 81.6% of the mothers had received information on the importance and signs of a proper baby latch. In the 'breastfeeding counselling' dimension, most mothers (41.5%) were advised to breastfeed their child exclusively up to 24 months of age or more and 31.7% up to 6 months of age. The mothers reported that in most cases (86.2%) they were informed about the advantages of breastfeeding, and 64.4% of them received information on their breastfeeding rights. In the third dimension related to 'breastfeeding protection/support', the mothers reported that most of the times (60.9%) the nurses were available and provided attention and support during feedings. We also wanted to understand if there had been a concern with the mother's intimacy while being taught how to position the baby to breastfeed and 62.1% of the mothers reported that most of times the nurses had this concern in mind. In the dimension related to trust/communication during the training sessions, most mothers mentioned that their feelings had been accepted and respected (85.4%) and that the eye contact and the tone of voice had been used correctly (57.5%). However, more than half of the mothers reported that they had only a few times received positive reinforcement, a compliment or encouragement, and 11.6% of them reported to have rarely or never received them.

Discussion
The decision to breastfeed and the success of breastfeeding depends on psychobiological, social, and cultural factors. Healthcare professionals' breastfeeding promotion interventions during the prenatal period, childbirth, postnatal period and the whole period of breastfeeding play a decisive role. In our study, 43.2% of the mothers considered the nurses' breastfeeding promotion practices to be fair, 29.5% of them considered them to be poor, and 27.3% of them considered them to be good. These data allows us to reflect on how breastfeeding is promoted. These data do not reflect the investment that has been made in the promotion, protection, and support of breastfeeding because the users' opinion still has not shown this breastfeeding promotion practice. In the dimension 'breastfeeding encouragement', most mothers reported to have been correctly informed about the schedule of feedings (when showing signs of hunger); however, a third of the mothers were advised to adopt a rigid schedule. The results on the use of pacifiers lead us to conclude that this is still a controversial issue without consensus. The difficulties that may occur during the initiation of breastfeeding are considered one of the main reasons for early weaning, including pain due to breast engorgement, sore nipples, mastitis, plugged duct, and breast abscess (Azevedo et al., 2010). In our study, the mothers' answers showed that the nurses had informed them correctly on the measures to be taken in these situations, as well as on the breastfeeding technique and the importance of a proper latch. The nurses are responsible for providing appropriate guidance on prevention and the procedures to be adopted to solve common problems during the breastfeeding process (Parizotto & Zorzi, 2008). As regards breastfeeding counselling and based on the results regarding the age up to which the child should be exclusively breastfed, there may have been a mistake in the interpretation of the question and the word «exclusively» may have been undervalued. The doubt remains as to whether the nurses are adequately informed about the current WHO recommendations which advocate the need to complement breastfeeding with other foods after 6 months of age. As for the information on breastfeeding advantages, the mothers' answers undoubtedly show that nurses value this topic.
In the dimension 'protection/support', the nurses' availability, attention and support during feedings should be highlighted, as well as the concern with the mother's intimacy as they teach them breastfeeding positions. In many hospitals, it is not always easy to respect women's privacy, since many services do not meet the necessary conditions to preserve the mother's intimacy. For this reason, mothers often have to breastfeed their children in front of healthcare professionals, family members and, in some situations, even relatives of women who have recently given birth and are on the bed beside them. Moreover, the mothers also reported that nurses were concerned with providing them with information on breastfeeding rights. In the dimension related to trust/communication between the mother and the nurse, the mothers felt that their feelings and thoughts regarding their decision to breastfeed were accepted/respected. In fact, the reality of each mother's lived experience should be valued, so that the decision to breastfeed is a choice of her own (Araújo et al., 2008). It is important to adapt our encouragement and counselling strategies, but we must also reflect on the evolution of the cultural patterns of motherhood over the last few years. Motherhood has gained a new meaning given the women's difficulties to reconcile the baby's needs and their own interests and the fact that the socially desired and expected profile of a good mother has become associated with breastfeeding the child with pleasure (Takushi, Tanaka, Gallo, & Machado, 2008). Thus, when the baby is not breastfed, the woman tends to have negative feelings, because she has to deal with a society where breastfeeding her child is the expected behaviour. The expressions does not want to breastfeed, doesn't like it, has no patience or is forced because they say that it is good for the baby do not match the profile of the ideal mother in a society where breastfeeding is highly promoted. We found that positive reinforcement of appropriate behaviours should be improved because encouraging and congratulating the mother for what she has done right will help her improve her self-confidence and achieve a satisfactory and successful breastfeeding experience. The nurse must be able to create a favourable environment for breastfeeding and establish a helping relationship, demystifying concerns and fears and responding to individual needs (Araújo et al., 2008).
In relation to the employment situation, there were significant differences in the dimensions 'breastfeeding encouragement' (p=0.019), 'breastfeeding counselling' (p=0.046), and the total perception of breastfeeding promotion practices (p=0.037). The mothers who work full-time outside the home have a more favourable perception of breastfeeding promotion. No association was found between the mothers' motivation and perception of breastfeeding promotion (p>0.05). Some studies have associated motivation with breastfeeding adherence (Rocha, Leal, & Maroco, 2008), but the focus of this study was not on adherence, rather on the mothers' perception of breastfeeding promotion. The fact that there are mothers who are motivated but not successful in breastfeeding may be related to the lack of guidance and support from healthcare professionals or more experienced people within and outside the family, which reinforces the relevance of our study. As regards the association between previous breastfeeding experiences and the perception of the nurses' breastfeeding promotion practices, no differences were found between the number of children and the perception of breastfeeding promotion practices. No studies were found that associated these variables. Some studies reported that early weaning is more common among mothers who breastfeed for the first time (Brown, Raynor, & Lee, 2011). Table 2 shows that the mothers' marital status is associated with the dimension 'counselling' (p=0.000) and the perception of breastfeeding promotion practices (total score) (p=0.000). The results of our study show that mothers who have the support of their husbands or partners are more motivated and emotionally stable, which can improve their perception of the nurse's guidance. Some analysed studies found that most women (69%) received support from their partners (Costa, Queiroz, Queiroz, Ribeiro, & Fonseca, 2013). With regard to the association between the level of education and the perception of breastfeeding promotion practices, we found that higher education was associated with higher perception of breastfeeding promotion. Based on the analysis of significance levels, we concluded on the existence of differences in terms of education in the dimensions 'breastfeeding encouragement' (p=0.043) and 'breastfeeding counselling' (p=0.030). The influence of education has been addressed in several studies and it has been demonstrated that the higher the educational level, the greater the motivation to breastfeed (Araújo et al., 2008) and the higher the rates of breastfeeding prevalence (Rebimbas, Pinto, & Pinto, 2010). Indeed, the mothers' level of education influences the correct understanding of the instructions and facilitates the access to information, which can contribute positively to a greater receptivity to breastfeeding. We conclude that, despite the motivation and the experience at the maternity hospital, the sociodemographic factors did not interfere with the mothers' perception of the nurses' breastfeeding promotion practices. However, marital status, level of education, profession, workplace, and working time were interfering factors. This study used a small-sized nonprobability sample, thus it cannot be generalised to the general population. We suggest that it be extended to primary health care due to the importance of anticipatory care on nutrition.

Conclusion
Our aim was to identify the mothers' perception of nurses' breastfeeding promotion practices with a view to determine the influence of sociodemographic and obstetric variables and previous breastfeeding experiences. It is important to give mothers a voice to obtain data to assess the nurses' breastfeeding promotion practices. User satisfaction is an important quality indicator and results from good practices, i.e. the users' wellbeing is reflected in their positive opinion about the quality of care provision (Pinto & Silva, 2013). In our study, we were surprised about the fact that nurses' practices were perceived as fair (43.2%) and poor (27.3%). These results are a source of concern and some questions emerge that may be discussed in clinical practice: Is it that nurses do not have the necessary training in this area and so they cannot transmit the desired safety and confidence to mothers?; Is it that, despite being properly trained, they still cannot adapt care to a specific mother and so she does not feel satisfied with the care provided or the practices?; Is it the mother's perception that is altered by the social pressure of being a mother, or a good mother, and so she is forced to breastfeed against her will?; Or is it that the interference of socio-economic and academic factors prevents mothers from paying attention to the nurses' breastfeeding promotion practices? Nurses are in a privileged position to promote and support breastfeeding, and it is their responsibility to encourage and help mothers to breastfeed. It is important to reflect on the nurses' practices in this area, with a view to understanding the reality and propose the planning and implementation of new interventions. Given the constant advancement of knowledge, more investment should be made in breastfeeding training and in the interpersonal communication/relationship with the users. In this way, nurses may position themselves in an objective, effective and integral way, avoiding some gaps in assistance, and thus contributing to reverse the rates of early weaning. We know that the transmission of knowledge from the professional to the mother is an arduous task; however, the nurse should be prepared to discuss this matter with the mother who is expected to breastfeed her child with pleasure.