evolução da pesquisa em aleitamento materno

REVISÃO REVIEW20

Cad. Saúde Pública, Rio de Janeiro, 21(1):20-28, jan-fev, 2005

Trends in breastfeeding research by Brazilian nurses

Evolução da pesquisa em aleitamento maternoconduzida pela enfermagem brasileira

1 Departamento de Enfermagem,Universidade Federal doCeará, Fortaleza, Brazil.2 School of Nursing,University of Virginia Health Systems,Charlottesville, U.S.A.

CorrespondenceD. F. GlickSchool of Nursing, Universityof Virginia Health Systems.P.O. Box 800782,Charlottesville, VA,22908, [email protected]

Mônica Oliveira B. Oriá 1

Doris F. Glick 2

Maria Dalva S. Alves 1

Abstract

Exclusive breastfeeding is acknowledged as im-portant for survival, optimal growth, and devel-opment of infants. The current review presents asynthesis of research output by Brazilian nurseson breastfeeding over the last 20 years, analyzesthe theoretical and methodological issues emerg-ing from studies on breastfeeding in Brazil, andprovides directions for future research and prac-tice by nurses in the area breastfeeding. Studiesincluded in this review were identified throughLILACS searches of Portuguese-language sources.Articles were organized and analyzed chrono-logically by comparing the evolution of theBrazilian Breastfeeding Program. The incom-plete research output of the Brazilian nursingprofession in regard to breastfeeding researchneeds to be addressed. In addition, specific cul-tural, sociological, and anthropological charac-teristics of Brazilian regional settings remain tobe explored. Emphasis on potential confoundersand critical interrelations is warranted.

Breastfeeding; Nursing; Nursing Research

Introduction

Exclusive breastfeeding is acknowledged as im-portant for survival, optimal growth and devel-opment of infants in low-income countries 1.Numerous investigators have reported a rela-tionship between breastfeeding and infanthealth. Such authors reveal that breastfed infantsexperience lower rates of acute and chronic oti-tis media 2, bronchiolitis 3, diarrhea 4, meningitis5, and necrotizing enterocolitis 6, suffer less re-current wheezing 7, have higher mean IQs 8, anddevelop insulin-dependent diabetes mellitusless frequently 9 than those who are bottle-fed.

Breastfeeding can also be beneficial to themother’s health by reducing the risk of ovariancancer and bone demineralization in compari-son to mothers who do not breastfeed their in-fants 10. Women who breastfeed are less likelyto develop osteoporosis and breast cancer 11,12,13

and are more prone to better social interac-tions 14. Therefore, exclusive breastfeeding hasbeen strongly recommended during the firstsix months of the infant’s life, continued bymixed nutrition until twelve months, accord-ing to World Health Organization (WHO) rec-ommendations. Indeed, in developing coun-tries, breastfeeding has proved to be an effi-cient strategy to improve child health and toprevent diseases in adulthood.

Over the last 20 years, Brazilian health poli-cy has encouraged breastfeeding programs in

BREASTFEEDING RESEARCH BY BRAZILIAN NURSES 21


an effort to prevent early childhood illnessesand to reduce infant mortality rates (IMR). Fortwo decades, breastfeeding campaigns havesuccessfully enhanced people’s commitment tohealth promotion on a large scale.

The Brazilian nursing profession has playedan important role in encouraging health inter-ventions in lactating mothers as a strategy toimprove exclusive breastfeeding rates and todecrease early weaning. However, the real im-pact of interventions by nursing teams in pre-venting early weaning and overall infant ill-nesses in Brazil is not well understood. Thecurrent review presents a synthesis of researchoutput by Brazilian nurses on breastfeedingover the last 20 years, analyzes the theoreticaland methodological issues emerging from stud-ies on breastfeeding in Brazil, and provides di-rections for future nursing research and prac-tice regarding breastfeeding promotion.

Methods

The studies included in this review were iden-tified through LILACS (Latin American andCaribbean Health Sciences Literature) search-es of Portuguese-language sources publishedsince 1983, by using the following key words:breastfeeding (aleitamento) and nursing (en-fermagem); breastfeeding, nursing, and Brazil.We chose the LILACS Database because it hasbeen the primary source of indexation for LatinAmerican journals. Further sources (97 refer-ences) were located by cross-referencing, butthis review includes only papers published inBrazilian nursing journals by Brazilian nurses.We excluded papers published in Brazilian andinternational nursing journals that were writ-ten in other countries and/or written by otherprofessionals. Books, book chapters, theses,and dissertations were also excluded becauseof the difficulty in organizing these materialsfor a review. Abstracts were excluded based oninsufficient information to be analyzed. Arti-cles were organized and analyzed chronologi-cally by comparing the evolution of the Brazil-ian Breastfeeding Program (BBP). A compre-hensive review and implications for future re-search and practices in breastfeeding by thenursing profession are presented.

Results

The literature searches identified 39 paperspublished in the eight main Brazilian nursingjournals: Acta Paulista de Enfermagem, Cog-itare Enfermagem, Revista Brasileira de Enfer-magem, Revista Gaúcha de Enfermagem, Re-vista Latino-americana de Enfermagem, REME– Revista Mineira de Enfermagem, Revista daEscola de Enfermagem da USP, and Texto & Con-texto-Enfermagem. We identified the numberof published papers according to the publica-tion date (Table 1). Among these papers, the au-thors used different study designs, as demon-strated in Table 2. However, for this review weconsidered only research articles (Table 3).While we were organizing articles by area, werecognized that most research output was fromSoutheast Brazil (n = 15). We found no articleswritten in North or Central-West Brazil. In or-der to improve the understanding of historicaltrends in nursing research, we did compar-

Table 1

Number of articles on breastfeeding published

by nurses in Brazil, according to publication date.

Date N %

1983-1987 4 10.3

1988-1992 6 15.3

1993-1997 8 20.5

1998-2002 21 53.9

Total 39 100.0

Table 2

Study designs in articles on breastfeeding

by authors in Brazilian nursing journals, 1983-2002.

Design N %

Reflection 1 2.6

Review 4 10.3

Report of experience 6 15.4

Update 7 17.9

Survey 21 53.8

Total 39 100.0

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isons within the BBP timeframe, organizing ourdata according to time windows.

First period: 1983-1987

The BBP was launched in March 1981 througha mass media campaign by television, radio,and print media advertising, reaching 20 mil-

lion households nationwide 15. However, thefirst paper published by nurses in breastfeed-ing research emerged in 1983 with a study byFadul & Xavier 16 and the second in 1986 withVale & Albuquerque 17. Both papers focused onweaning. These authors aimed to understandwhy mothers weaned their babies early. Fadul& Xavier 16 observed that 42 (70.0%) of mothersweaned their babies before three months. Para-

Table 3

Characteristics and distribution of articles on breastfeeding published in Brazilian nursing journals, 1983-2002.

Study Location Subject Type of study Theoretical Research toolscharacteristics framework

1 Fadul & Xavier 16 Ribeirão Preto (SE) 60 mothers Exploratory Interview(prospective)

2 Vale & Albuquerque 17 Fortaleza (NE) 10 mothers Exploratory Interview(prospective)

3 Scochi et al. 18 Ribeirão Preto (SE) 76 puerperae Exploratory Structured interview(prospective)

4 Silva 19 São Paulo (SE) 25 puerperae Quasi-experimental Medical records and (prospective) structured interview

5 Scochi et al. 20 Ribeirão Preto (SE) 92 puerperae Descriptive Structured interview(prospective)

6 Marcon 22 Maringá (S) 60 mothers Exploratory Ground theory Participant observation(prospective)

7 Almeida 23 Salvador (NE) 36 mothers Qualitative Historical Semi-structured interview(prospective) materialism

8 Abrao et al. 24 São Paulo (SE) 12 puerperae Descriptive Nursing consultation using (post-cesarean) (prospective) research forms

9 Boehs 25 Florianópolis (S) 46 mothers Exploratory Questionnaire(prospective)

10 Pereira et al. 26 Ribeirão Preto (SE) 10 nurses Qualitative Semi-structured interview(prospective)

11 Silva 27 Ribeirão Preto (SE) 42 nursing students Qualitative Symbolic Participant observation (prospective) interactionism and interview

12 Harada et al. 28 São Paulo (SE) 66 mothers whose Cross-sectional Interviewinfants were hospitalized (prospective)

13 Grazziotin & Curitiba (S) 300 mother-infant pairs Quasi-experimental Nursing consultation and Yamasaki 29 (prospective) infant physical exam

14 Pinelli & São Paulo (SE) 130 first-time mothers Randomized Andragogy Structured interviewFriedlander 30 (prospective)

15 Rozario & Zagonel 31 Curitiba (S) 15 mothers Descriptive Philosophy and Educative seminars, nursing (prospective) science of caring history and interview

16 Machado et al. 32 Ribeirão Preto (SE) 22 mothers Qualitative Semi-structured interview(prospective)

17 Nakano & Mamede 33 Ribeirão Preto (SE) 20 mothers Qualitative Feminist theory Semi-structured interview(prospective)

18 Nakano & Mamede 34 Ribeirão Preto (SE) 22 mothers Qualitative Semi-structured interview(prospective)

19 Ichisato & Shimo 35 Ribeirão Preto (SE) 3 women of the Case study Semi-structured interviewsame family (retrospective)

20 Oscar et al. 36 Belo Horizonte (SE) 6 puerperae Qualitative Phenomenology Interview(prospective)

21 Abrao et al. 37 São Paulo (SE) 181 mother-infant pairs Descriptive Interviews with mothers and analytic and physical examination (prospective) of infants.

Regions of Brazil: NE = Northeast; S = South; SE = Southeast.



doxically, mothers with more schooling weanedeven earlier, as follows: illiterate mothers, 4(6.6%); mothers with complete high school, 17(28.5%). In addition, urban women (n = 38,63.3%) were more likely to wean their babiesbefore three months as compared to rural moth-ers (n = 4, 6.6%).

According to Vale & Albuquerque 17 the maincauses of early weaning were: (1) pediatrician’sadvice to use formula milk; (2) suppression ofbreastmilk because of fear; (3) “lumping” ofmilk attributed to the baby’s burping duringbreastfeeding; (4) contraceptive use; (5) con-cern about the breasts’ appearance; (6) moth-er’s concern about the possibility of acquiringillnesses due to calorie loss; and (7) prioritizingdomestic tasks.

Based on their findings, Vale & Albuquerque17 strongly recommended reinforcing attitudestoward breastfeeding during prenatal and pe-diatric consultations (especially in the first sixmonths postpartum), in order to further encour-age women’s adherance to exclusive breast-feeding practices for a much longer period.

Second period: 1988-1992

In 1988, four new policies in favor of breast-feeding practices were consolidated in Brazil,representing a historical turning point in theprogram: (1) the National Ruling on Commer-cialization of Infant Foods; (2) Ruling on Hu-man Breast Milk Banks; (3) inclusion of theright to a four-month maternity leave in theBrazilian Constitution; (4) inclusion of theright to a five-day paternity leave in the Brazil-ian Constitution.

During this critical period of establishingand maintaining the first program goals, nurs-es began playing a more active role in the newBBP, as shown by three articles on breastfeed-ing 18,19,20. These studies used different de-signs and focused on different themes (feed-ing regimens, breast engorgement, and moth-er’s knowledge about breastfeeding). Neverthe-less, the general focus was on women’s health,revealing the awareness of Brazilian nursesconcerning women as important promotersand recipients of health care during the lacta-tion process.

According to Scochi et al. 18, 85.53% (n = 65)of mothers interviewed offered breast milk ona self-demand scheme, and 91.1% of their de-cisions about breastfeeding practices were inaccordance with proper technical procedures.Among 11 (14.47%) mothers who chose tobreastfeed according to a rigid schedule, 33.0%

justified their choice based on a hospital rou-tine in which a baby is fed every three hours.While hospital routines are conducted to opti-mize the work in the hospital environment,they may not always work in the home context.Some mothers learned and replicated thesepractices at home because they believed thatthis model was better for feeding their babies.

Silva 19 tested a systematized procedure ofnursing care for mothers with breast engorge-ment. The intervention represented a combi-nation of three different techniques: massagewith an electric vibrator, suckling stimulus forthe baby, and hand manuevers for the mam-mary glands. The combination of these tech-niques was termed the “Systematic NursingCare Procedure”, applied after each feed untilthe engorgement regressed. According to herfindings, therapeutic sessions were 4.4 timesmore common in women with glandular breastengorgement and resulted in a reduction in to-tal breast engorgement after an average of 6hours and 54 minutes for the lobar type and 11hours for glandular breast engorgement. Re-gression time was longer in women with lowbirth weight babies and in those whose babiesremained less time suckling. Nursing interven-tion was efficient by decreasing symptoms ofbreast engorgement, preventing cracked nip-ples, and avoiding other common complica-tions related to breast engorgement, in addi-tion to promoting women’s self-care duringtreatment.

In another study of 92 women by Scochi etal. 20, 73 mothers (79.34%) were assisted at pre-natal care units. Of these, 65 (89.04%) did notreceive any nursing assistance related to infantcare. Among the themes chosen by the re-searchers to evaluate educational programs,care with the umbilical cord stump was pre-ferred by the women in the study, reaching ahigher learning index than other items mea-sured at hospital admission and discharge. Inaddition, primiparous mothers showed morepositive attitudes towards technical aspects ofinfant care. All mothers in the study showedwillingness to breastfeed, as evaluated at bothadmission and discharge. However, a possiblebias is that the women might be more prone tobreastfeed by convenience during hospitaliza-tion, fearing retaliation from the health careteam and failing to disclose their real decisionsabout intended breastfeeding practices. In ad-dition, the study was not extended to the homelevel, so women’s knowledge and breastfeedingpractices outside the hospital remained insuf-ficiently explained. Moreover, the time elapsedbetween admission for normal delivery or ce-

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sarean and hospital discharge may not be suf-ficient to evaluate real behavioral changes in afamily context.

Third period: 1993-1997

In 1992, the implementation of the “Baby-Friendly Hospital Initiative” in Brazil enhancedprevious goals to fulfill “ten steps to successfulbreastfeeding” by highlighting the natural ad-vantages of breast milk and not encouraginguse of milk substitutes. Several hospitals wereenrolled in this program. However, in 1996 theBrazilian Ministry of Health decided to add fur-ther requirements for enrollment, especiallyfocused on lowering cesarean rates and thussubstantially impacting new enrollments in thisprogram 21. During this period, four new studieswere published by Brazilian nurses 22,23,24,25.

The study by Marcon 22 highlighted theprocess, concepts, and women’s experiencesduring weaning. Study participants unexpect-edly supported an age limit for breastfeeding(≅ 1 year old). After this age, they believed thatbreast milk would no longer provide adequatenutrition. In addition, they were strongly influ-enced by their social groups toward weaningpractices, contributing to the high weaningrates in this population.

A second study by Almeida 23 addressedwomen’s emotions during the process of earlyweaning. Data revealed that breastfeeding wasa dynamic social practice, constantly in recon-struction, with continous shaping and remod-eling. Breastfeeding and weaning were inter-mingled with myths, misconceptions, and prej-udices based on historical and sociologicalbackgrounds. Women’s emotions during breast-feeding and weaning were shown to be relatedto historical momentum and ongoing educa-tional processes. When guilt was identified as anemotional component of the weaning process,the women began finding excuses to justify theirweaning decision and redeem themselves. Theauthor found several meanings underlying theweaning response, including indifference, sac-rifice, guilt, pleasure, relief, and exploitation.

The third study, by Abrao et al. 24, designeda model for data collection to validate theNANDA-I (North American Nursing DiagnosisAssociation, Taxonomy I) generally used as adignostic tool in breastfeeding practices. Infor-mants were provided with nursing couselingon the 7th and 15th days after delivery. The au-thors found that among 25 nursing diagnosesfrom the instrument, only 13 (52.0%) were clear-ly identified in this population, justifying the

need to reevaluate the tool. However, the sam-ple was limited to post-cesarean women andthus did not consider the needs of women whohad experienced vaginal delivery. In addition,the sample was too small (n = 12) for more con-clusive findings and was thus inappropriate tosuggest replacing the NANDA tool in regard tobreastfeeding.

The last study in this period was publishedby Boehs et al. 25, who analyzed the breastfeed-ing experience up to the 6th month after birthusing interviews with mothers at 15 days and 2,4, and 6 months after delivery. These researchersfound that 41.3% (n = 19) of the mothers breast-fed their babies at the 6th month, but only15.2% (n = 7) exclusively breastfed. In the firstinterview, 26.0% (n = 12) had introduced otherfoods into the baby’s diet. Causes of low exclu-sive breastfeeding rates were grouped as fol-lows: (1) mothers who were unable to breast-feed; (2) infants who were incapable of beingbreastfed; (3) mother’s beliefs; (4) the pediatri-cian’s orientation; and (5) family influence.

Such findings highlight the importance ofcontextual and cultural factors in the decision-making process on breastfeeding and the fami-ly’s key role in supporting and influencing amother’s decisions. Educational programs tar-geting these factors are critically important.Difficulties in breastfeeding were more fre-quent in the first interview (15th day after de-livery). By experiencing breastfeeding for thefirst time and after receiving adequate counsel-ing from researchers about how to deal withcommon problems, mothers had become moreconfident and were more prone to sustainbreastfeeding.

Fourth period: 1998-2002

Since 1999, the Ministry of Health has imple-mented new policies regarding milk formula,pacifiers and baby bottles for companies, whichare contradictory to the National Ruling onCommercialization of Infant Foods. In 2000-2001 the ruling was reviewed, extended, andelaborated in greater detail 21.

We identified 12 articles published duringthis period, two of which focused on breast-feeding 26,27. Silva 27 conducted a prospectivestudy to evaluate breastfeeding representationfor nursing students in order to understandtheir conceptions concerning care for the moth-er-infant pair during the lactation process. Ac-cording to nursing students, the most impor-tant meaning was “be there with the mother”,to support and counsel mothers, an approach



they felt would result in increased breastfeed-ing rates. Thus, from the student’s perspective,nursing care was considered more than just atechnical issue.

Pereira et al. 26 studied the relationship be-tween the health model implemented underthe Unified National Health System (SUS) andcurrent practices in a primary care center. Nurs-es reported some operational difficulties dueto disagreements between the nurses’ (holistic)and physicians’ (segmented) approaches. Nurs-es in the study by Pereira et al. reported thatbreastfeeding practices should not be separat-ed from the health policy context, and there-fore breastfeeding promotion strategies shouldaddress local needs, underpinned by profes-sional availability, investment in human re-sources, and periodic and systematic assess-ment of outcomes.

Harada et al. 28 aimed to identify factors as-sociated with early weaning and mixed nutri-tion (breast milk + other milks or teas) in hos-pitalized infants. These researchers suggestedthat early weaning was directly related to themother’s lower schooling. Other factors were:“insufficient milk” (44.0%), “lack of milk”(35.0%), and “mother’s occupation” (8.0%). Themain causes of infant hospitalization were bron-chopneumonia and pneumonia with or with-out complications (71.2%) and diarrhea (27.3%).

During the review, we identified only onestudy focusing on premature newborns 29, high-lighting nursing care in human breast milkbanks (HBMB), a practice which has played asignificant role in increasing weight gain inpremature newborns after hospital discharge.This study followed 300 infants every 72 hoursuntil they began gaining weight (18g/day or125g/week). In the first assessment, only 33(11.0%) infants showed higher weight than be-fore hospital discharge. However, other infantsenrolled in this study exhibited insufficientweight gain (24.0%) and even weight loss(65.0%). Nursing care in HBMBs during thesecond assessment was critical for improvedweight gain in that group, with only 5.1% pre-senting weight loss. Among premature infantsshowing weight loss or insufficient gain, sever-al factors were associated with these outcomes,including cultural influences, specifically taboosand beliefs such as “weak milk” and “smallamount of milk”. In addition, the authors re-ported other important factors such as theneed to complement the infant’s diet with wa-ter and tea, uncertainty about breast milk qual-ity, incorrect breast maneuvers during suck-ling, stress, inadequate management of thebreast before, during, and after breastfeeding,

and insufficient sleep. The data emphasized theimportance of regular follow-up of mother-in-fant pairs to encourage successful breastfeedingand promote the health of premature infants.

Concerned with education for first-timemothers, Pinelli & Friedlander 30 developed aneducational program based on an andragogymodel, highlighting two main themes: “breast-feeding and breast care” and “newborn infantcare”. Healthier babies and fewer maternal com-plications were seen in the group of womenwho had chosen educational programs as com-pared to the other group that was enrolled ineducational activities arbitrarily chosen by nurs-es. The authors highlight the need for targetedprograms, including themes previously designedto meet the client’s own needs. According tothese findings, women should decide what andhow much they need to learn. Such a personal-ized group approach would require that nurseshave a wider range of technical and specializedtraining on breastfeeding issues, learning andteaching skills to assess individual needs.

Rozario & Zagonel 31 implemented interac-tive activities in hospital rooming-in by utiliz-ing an educational approach. They have sug-gested more effective actions by identifying themother’s own needs in regard to breastfeeding,and consequently providing more personalizedand more meaningful holistic care.

In a series of three publications, Nakanoand colleagues discuss issues in the decision-making process, breastfeeding practices, andwomen’s right to breastfeed 32,33,34. The authorsstudied breastfeeding practices from a femaleperspective and suggested that breastfeedingrepresents a feminine prototype to socially qual-ify for women’s role in society 33. In addition,according to these researchers, women sufferfrom ambivalence between self-adjustment(obligation, giving, and sacrifice) and resistance(physiological inability to breastfeed). This con-flict causes more distress and frustration dueto their inability to sustain “a model of ideal-ized motherhood” required by the social group.

Machado et al. 32 identify three importantcomponents in the decision-making processon breastfeeding: family, health professionals,and the media. In regard to family issues, theseresearchers found a beneficial role in the hus-band/father. Family factors can positively in-fluence the decision-making process on breast-feeding. In regard to professional care, a majorconcern was the importance of appropriatemaneuvering to breastfeed, revealing a prefer-ence for a biological approach in nursing. Inaddition, these authors emphasize the advan-tages of technical education to encourage lac-

Oriá MOB et al.26


tating woman. Lastly, the media was importantfor women’s understanding of the advantagesof breast milk.

In the last study of the series, Nakano &Mamede 34 analyzed the social environment inwhich Brazilian women are immersed duringbreastfeeding, focusing on female employees.The authors highlight a Brazilian national lawgranting a 120-day leave for women to breast-feed at home. They explored the model’s feasi-bility, which does not currently cover womenin the informal labor market, apart from thelaw’s benefits. In addition, even for womenwho are likely to be granted these 120 days athome, at the end of the breastfeeding leavethey are unable to continue breastfeeding be-cause of the scarcity of daycare centers neartheir places of work. In turn, this 120-day em-ployment leave to breastfeed changes women’sbehavior and promotes a more flexible role asspouse, mother, and employee, whereby womentend towards household and spousal roles, de-clining to play a productive role in society. Thisrestriction to household life can have a tremen-dously negative impact on family income, be-sides increased dependency on the husband.These researchers identified the importance ofnursing care to promote breastfeeding, not on-ly biologically, but also in assisting womenwithin their historical social context.

Ichisato & Schimo 35 conducted a studywith three women from the same family in dif-ferent generations (mother/daughter/grand-daughter) in order to analyze feeding traditionsduring breastfeeding. These investigators high-lighted that breastfeeding is not only a biologi-cal issue, but also historical, sociological, andpsychological. It can be heavily influenced byculture, beliefs, and philosophical concep-tions, which in turn can take the form of a so-cio-cultural legacy elaborated through distinctfamily meanings in the woman’s world. Thisbehavior was clearly evidenced when mothersstarted using milk secretion stimulants (fromregional galactogogue sources), which weremainly chosen through mother-to-daughtercommunication in situations of hypogalactia.The women usually try a variety of fruits, juices,fish, poultry, milk, cheese, tea, and chickensoup of dubious pharmacological benefit be-fore seeking professional aid.

Oscar et al. 36 conducted a qualitative studyon meanings ascribed by lactating women af-ter breastfeeding counseling. These authorsidentified that nursing counseling helped tofoster behaviors involving comfort and confi-dence during breastfeeding and better relation-ships between mother-child pairs by strength-

ening bonds and creating opportunities forself-expression and questioning. Based on thesefindings, the authors suggest a complete nurs-ing follow-up at least during the first steps ofbreastfeeding. This nursing support aims toavoid frustration, difficulties, and behavioralerrors which could jeopardize the early breast-feeding process and ultimately facilitate earlyweaning.

Abrao et al. 37 recently conducted a descrip-tive and analytical study enrolling 181 womento clinically validate the key characteristics ofeffective breastfeeding diagnosis under NAN-DA-I. The authors validated 5 constant charac-teristics: (1) the child’s ability to find the nippleand areola; (2) signs and/or symptoms of oxy-tocin release; (3) regular and sustained suck-ling/swallowing at the breast; (4) infant con-tentment after feeding; and (5) normal bowelmovement patterns for age.

Discussion

Based on a historical overview of nursing re-search on breastfeeding practices in Brazil, wehave identified growing research interest inbreastfeeding outcomes related to recommen-dations by the Brazilian Breastfeeding Program.The research approach was based on a women’shealth perspective rather than a more variedpoint of view such as the family context or oth-er health paradigms, including structural andoperational issues and local policies. Only onearticle published in Brazilian nursing journalsdirectly addressed the benefits of breastfeed-ing for child care 29.

Most of the papers used a qualitative ap-proach to examine the benefits of breastfeed-ing. Few studies used quantitative data to eval-uate independent variables about successfulbreastfeeding rates. Surprisingly, no studiesused more rigorous statistical analyses, such asmultilinear regression models and multivariatecorrelations as the basis for more powerfulfindings. Additionally, some aspects of ecologyand environmental relationships are still fre-quently understimated. The scarcity of quanti-tative research limits the portrayal of intercon-textual and intracontextual relationships be-tween different variables. The lack of studiesthat acknowledged potential confounding fac-tors or employed more refined research de-signs underline the significant need for morerigorous research by the nursing profession onbreastfeeding in Brazil.

Among the 21 articles reviewed, only sevenwere supported by a theoretical framework.



Theories were diversified and sometimesbroadly assessed. Importantly, no studies cen-tered on culturally dynamic subjects by usingethnography and ethno-nursing. We empha-size the importance of the cultural approachfor nursing research because of the socio-cul-tural peculiarities of each Brazilian region. Ac-cordingly, it is critical to shape novel BBPstrategies that are appropriate for regional cir-cumstances in order to fulfill local health pri-orities.

Appropriate health information is especial-ly important for primigravid women and moth-ers who have experienced previous problemswith breastfeeding. It has been shown thathighlighting the advantages of breastfeedingfor the child and mother and providing techni-cal and material support for breast preparationis not sufficient to successfully increase breast-feeding rates. Women need to receive specialnursing assistance and appropriate culturalcare in local communities in order to interruptan unhealthy behavioral cycle and define newhealth attitudes and concepts. Brazilian nurses

can actively encourage breastfeeding practicesby being more accessible to local communitiesand offering technical and emotional supportfor new mothers. Nurses can identify the cul-tural and family issues related to prevalent be-haviors.

In short, we found a lack of consistent nurs-ing data from the North and Northeast regionsof Brazil. Peculiar cultural, sociological, andanthropological characteristics of Brazilian re-gional settings remain to be explored. Empha-sis on potential confounders and critical inter-relationships will enhance the validity of re-search outcomes. The lack of continued stud-ies in the nursing field has resulted in a knowl-edge gap in theoretical and nursing practicesin various areas, especially those with the great-est needs. The unfinished task of the Braziliannursing profession in regard to breastfeedingresearch needs to be addressed urgently in or-der to creatively and efficiently gather andmanage relevant public health data aimed atplanning appropriate intervention strategies.

Contributors

The authors all contributed equally to the prepara-tion of this manuscript.

Resumo

Sabe-se que o aleitamento materno exclusivo é impor-tante para a sobrevivência, crescimento e desenvolvi-mento infantil. Os objetivos desta revisão foram: apre-sentar uma síntese da produção intelectual da enfer-magem brasileira na área do aleitamento materno nosúltimos vinte anos, criticar questões teóricas e meto-dológicas dos estudos, e providenciar direções para fu-turas pesquisas e práticas de enfermagem em relaçãoao aleitamento materno. Os estudos incluídos nestarevisão foram identificados por meio de busca no LI-LACS para estudos publicados em português. Os arti-gos foram organizados e analisados cronologicamen-te, traçando uma comparação com a evolução do Pro-grama Nacional de Aleitamento Materno. A lacuna dapesquisa em aleitamento materno pela enfermagembrasileira precisa ser preenchida como uma agendaprioritária. Além disso, as peculiaridades culturais, so-ciológicas e antropológicas que caracterizam cadaregião brasileira precisam ser exploradas. A ênfase empotenciais co-fatores e suas inter-relações críticas pre-cisa ser melhor explorada.

Aleitamento Materno; Enfermagem; Pesquisa em En-fermagem

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Submitted on 11/May/2004Final version resubmitted on 20/Aug/2004Approved on 24/Aug/2004

evolução da pesquisa em aleitamento materno

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