KNOWLEDGE AND ATTITUDES OF PUERPERAL WOMEN RELATING TO BREASTFEEDING IN A UNIVERSITY HOSPITAL

Breastfeeding (BF) has presented, among other benefits, a reduction in infant mortality, a prevention of respiratory infections and a reduction in the risks of developing diseases. Therefore, the objectives of this study were to evaluate the knowledge and attitudes of puerperal in relation to BF in a university hospital, as well as the sources from which this information was obtained and the professional categories responsible for same. The work was carried out at the Hospital das Clinicas, Federal University of Uberlândia (HC-UFU). Structured interviews were conducted to obtain data for the evaluation of information and exercise of the BF practice with puerperal hospitalized in the accommodation complex, for mother and child, from July 1 to December 31, 2010. Of the total of 907 women interviewed, 617 (68.0%) intended to BF for 12 months or more, 566 (62.4%) performed the BF within the first hour of birth, in 551 cases (60.8%) the decision to BF was taken by the woman before the current pregnancy and 828 (91.3%) received help in BF. Of the women who received help, 788 (95.1%) were assisted by professionals from the nursing team. It was shown that the majority of the puerperal intended to breast-feed for 12 months or more, considering that they also carried out BF in the first hour after child birth. The study also noted the importance of the nursing staff in taking care of the mother/child pair, promoting better interaction and acceptance of BF.


INTRODUCTION
In recent years there has been an important advance in attention to the clinical management of breastfeeding (BF) as well as in conducting research on this topic (KOKSAL, 2015).The World Health Organization recommends that exclusive breastfeeding (EBF) be started from birth and continued until the 6th month of age, introducing complementary foods as from 6 months and the BF to continue until the child is two years of age or more (BRASIL, 2014).
A number of authors discuss and demonstrate the benefits of EBF in the first six months of life for the child and point out that human milk is essential to reduce infant morbid mortality.In addition, the EBF helps prevent respiratory infections, reduces the risk of developing diseases, promotes the affective mother/child bond and the best psychomotor and cognitive development, with the consequent increase of the individual's quality of life (SOUZA, 2013;AYTEKIN, 2014).
Women's knowledge and attitudes have an impact on various aspects of BF, such as establishment and its duration.Studies show that by improving the attitudes of mothers in relation to the act of breastfeeding, especially among those who are younger and of lower level of awareness in early pregnancy can significantly increase the duration of the BF and promote its earlier start (SHAMS, 2011;QUEENAN, 2011).Despite the relevance of the theme, few studies as to the barriers and lived experiences of women have been published (AMERICAN ACADEMY OF PEDIATRICS, 2012).
Strategies to promote, protect and support BF should include a component of information, education and communication, in order to influence mothers and family members through knowledge about BF (WALLWIENER, 2015).The greater and more qualified the knowledge about BF among women, the more confident they will be with their personal abilities to breastfeed (SHARP, 2015).
In this context, the objectives of this study were to evaluate the knowledge, the puerperal attitudes about BF in a university hospital, as well as the sources from which this information was obtained and the professional categories responsible for same.

Procedures
The work was carried out at the Hospital das Clinicas, Federal University of Uberlândia (HC-UFU).The study population consisted of puerperal admitted to the Accommodation Complex, aged from 10-50 years old.All puerperal in the period from July 1 st to December 31 st 2010 who agreed to participate in the survey and signed the free and informed consent form (ICF) were included.The under 18 women were included within the same criteria and the ICF was signed by their legal representatives.The puerperal who had conditions that indicated against BF were excluded, those carrying the Human Immunodeficiency Virus (HIV), human T cell lymphotropic virus (HTLV), and those who refused to participate in the survey as well as those infant was admitted to or transferred to the Neonatal Unit (NU).
The puerperal were invited to participate in the interview, between six and twenty-four hours after delivery.At that time, the study proposal was presented and possible doubts were clarified.After signing the ICF, the woman was interviewed by a previously trained member of staff.The structured interview had an average duration of 15 minutes, and the questions were asked orally by the interviewer.The questionnaire consisted of 23 questions with multiple choice answers (Annex 1).It was structured on the basis of other researches on BF (CALDEIRA, 2000;NAKAMURA, 2003, MARRONE, 2008).It was made up of six socio demographic questions (1-6); six obstetric (7-12), eight BF (12-20) and three questions about the support of health professionals for BF (21)(22)(23).So that no interference could occur in the results of the study, the approach to the woman, and the interview, always took place before having educational lectures about BF for the studied group.
This study was approved by the Ethics Committee of the Federal University of Uberlândia -MG, under protocol number 107/2010.

Data analysis
The results were described in frequencies that were absolute and showed percentage.So as to evaluate the association of socio demographic variables and information about BF, the Chi-Squared Test (χ 2 ) was used, considering as statistically significant those results with p<0,05.All the statistical analyzes were carried out using the SPSS program, version 17.0 (Statistical Package for Social Science, 2008).

RESULTS
Nine hundred and seven (907) percentuais of the 1,206 women who gave birth in the HCUFU during the study period were interviewed.The main reason for exclusion was the transfer of the newborns to the progressive care Neonatal Unit (n=262).Other reasons for non-inclusion in the study group are shown in Figure 1.The socio-demographic and gestational characteristics of the women interviewed are described in Table 1.It was found that 61% were less than 25 years of age, 75% had not completed high school and 57.3% had a stable union.In all, 617 (68.0%) of the women reported that they intended to BF for 12 months or more, 566 (62.4%) of the women had BF within the first hour after birth.The decision to BF was taken by the women before the present pregnancy in 551 (60.8%) of the cases and 467 (51.5%) of the respondents reported having received information about BF during prenatal care.The beginning of complementary feeding is intended until the 6th month of life of the child in 816 (90.0%) cases.After delivery, 219 (24.1%) women reported having received guidance on Bf and 828 (91.3%) received help as regards to the breastfeeding process.The main professional category responsible for the technical support as to BF was the nursing staff, with 788 (72.7%) women being assisted by these professionals (Table 2).The analysis of socio demographic, obstetric (prenatal, gestational age, parity) and BF data in relation to information received about breastfeeding (Table 3) showed a statistically significant association regarding education (P=0,007), prenatal (P=0,046), gestational age (P=0,003) and decision to breastfeed (P<0,006).Private prenatal care showed itself to be associated with the highest levels of education, occupancy rate and family income (P<0,001), and with less information about BF (P<0,046).

DISCUSSION
Breastfeeding (BF) is the most natural form of newly born nutrition.It provides psychological and health benefits for both the mother and the child.The decision to BF is complex and depends on multiple factors such as biological, psychological, social and educational (SILVA, 2013;SEIGHALI, 2015).
The education of mothers as to the importance and duration of BF is essential for the establishment of BF which results in promoting the health of the children (SEIGHALI, 2015).Among the main factors contributing to the success BF are included personal convictions, family influence and the support of health professionals (BARCLAY, 2012).
A number of authors have discussed the factors associated with BF on a worldwide basis, among which the influence of socio demographic characteristics of the percentuais are worthy of note.Thus, the discussion of these variables can reveal cultural trends of a population group as regards BF (SILVA, 2013;BIKS, 2015;SALUSTIANO, 2012).
The results of this study show a young age pattern with an average age of 24.9 years (13-44 years) compared to other studies (SILVA, 2013;SALUSTIANO, 2012).At HC-UFU a significant number of births by adolescent mothers (21.6%) was also observed compared to 14.6% of the overall average for the municipality of the area of research (BRASIL, 2012a).
According to Barbieri, the marital status of the woman may be linked to the success of BF (BARBIERI, 2015), in the present study findings The level of education of the woman also shows itself to be relevant to the investigation as to the knowledge, attitudes and practices related to BF (FOX, 2015).In this study, the level of education of most of the women was high school or university graduate.Similar results have been described in other studies (SILVA, 2013;SALUSTIANO, 2012).
The HC-UFU, whose attendance or service is exclusively through the Unified Health System of Brazil, serves a population with lower purchasing power.Although most respondents have completed high school or university, this study showed that family income was between one and three minimum wages for the majority of the women.Moreover, most of them (57.9%) were housewives, not exercising any academic or paid activity.One important factor for the success of BF is prenatal, where it is recommended that the mother to be carries out at least six consultations, be they in the public or in the private health network (OLIVEIRA, 2012).The pregnancy period has been considered an opportune time for appropriate guidelines to be given as to BF and prepare the mother to be for BF (BRASIL, 2012b).The public health system in the municipality of Uberlândia has installed a prenatal program with dissemination and incentive for its accomplishment.This study showed that 96.9% of the women, who underwent prenatal in the public service, had a minimum of six visits, similar to the guidance from the Ministry of Health (MAZARIEGOS, 2015;BRASIL, 2012a).
The results of this study show that prenatal care was the main source of information as to BF.Despite the significant number of percentuais (48.5%) who did not receive information about BF during the last pregnancy, those who received (51.5%) obtained the information during the prenatal period, reinforcing the importance of this practice during pregnancy.The Ministry for Health annually launches advertising campaigns in support of BF, valuing its airing through the media (BRASIL, 2012b).Thus, it is worth noting that in the group investigated 18.8% of the women indicated the media as a source of information as to BF.
The intention of the women regarding the duration of BF found in the study is at least 12 months of a child's life for 68.0% of the participants.This result agrees with the research carried out in the Brazilian state capitals where the medium or average duration of 11.2 months of BF was found (VENANCIO, 2013).This study reveals a promising outlook when compared to the results found in a study developed in Jordan, where 37% of mothers considered a three months period as the adequate time to breastfeed their children (GRIMSHAW, 2013).
The study carried out in Brazilian state capitals and in the Federal District, the results indicated the panorama of BF in the country (VENANCIO, 2013).The percentage of children who were breastfed in the first hour was 67.7% in the country, with the Southeast averaging less than the national value with 63.5% of children breastfed in the first hour of life.According to these parameters from the WHO for BF in the first hour of life, Brazil is classified as "Good" with percentage variation of 50 -89% of BF in the first hour.This study shows similar data, with 62.4% of the women interviewed carrying out BF in the first hour of life of the child.It is important to mention that only the woman's intention to breastfeed does not guarantee the complete success of the practice.It requires the attention from health teams, as they are the health professionals who are fundamental for the success of BF and who perform an educational role in promoting breastfeeding and prevention early weaning (SILVA, 2014).
According to Hackman e Alves, the greater the level of education, the better the type of prenatal care the more likely will be the decision to breastfeed.Supported by such data, when variables associated with the received information about breastfeeding were evaluated, the results were statistically significant for higher education, type of prenatal care, gestational age and decision to breastfeed (HACKMAN, 2015;ALVES, 2013).
Pregnancy is an important time to orientate and raise the awareness of woman as to BF.For some authors, education on BF practices should occur before pregnancy, from the early school years so that children and young people could learn about the advantages of BF, its establishment and maintenance in addition to the importance of this practice for the child's development (OOSTERHOFF, 2014).A finding of this study was that 60.8% of the women interviewed had decided to breast-feed before pregnancy, probably due to information and experience acquired previously.
As regards the investigation of the association of the type of prenatal carried out, be it public or private, and the studied variables, such as education, occupation, family income and information as to BF, statistically significant differences were found.Most of the women (90%) carried out the monitoring of pregnancy in the Free public health sector, so that the assessment may not be real due to the low number of women, 27 (3.1%),who underwent prenatal care in the private service sector.
The health workers of the hospital investigated developed educational and caring activities related to BF.It is expected that teaching hospitals be committed not only to caring, but also to education in health and research (SALUSTIANO, 2012).The results of this study show that the involvement of service nursing staff with issues related to BF was greater than that of other professional categories, probably due to greater contact with the mother and newborn and the development of ones function as a caregiver.Other studies have shown the important role of the nursing professionals in the promotion, support and encouragement as to BF. (SILVA, 2014;WARD;BYRNE, 2011).
After delivery 219 (24.1%) women reported having received orientation on BF and 828 (91.3%) received help in BF.The main professional category responsible for the technical support as to BF was the nursing staff, of which 788 (72.7%) women were assisted by these professionals.The results obtained from the study suggest that the training of health professionals, particularly nursing staff, could change the BF practice, as these are considered the main source of information for mothers, especially for the first time mothers (SILVA, 2014;WARD;BYRNE, 2011).
The current study, although it was carried out in only one hospital, suggests the need to implement health education programs focusing on BF not only for prenatal and likewise suggests the establishment of actions that enable all healthy mother-child binomials can experience the establishing of BF in the first hour post-partum.

CONCLUSIONS
The majority of the puerperal received information about BF during the current pregnancy, and the prenatal was referred to as the main source of information.
Nursing professionals are pointer out or mentioned as the main agents responsible for orientation and assistance in the establishment of breastfeeding.

Figure 1 .
Figure 1.Distribution of women who gave birth within the study period.

Table 2 .
Answers to the questionnaire on information, orientation and aspects related to BF, Uberlandia (MG)
*Χ 2 The total number for the variable 'Type of prenatal' is 889, as 18 women did not have monitoring during pregnancy.