EvoluçãO Da Pesquisa Em Aleitamento Materno

20 REVISÃO REVIEW

Trends in breastfeeding research
by Brazilian nurses

Evolução da pesquisa em aleitamento materno
conduzida pela enfermagem brasileira

Mônica Oliveira B. Oriá 1

Doris F. Glick 2
Maria Dalva S. Alves 1

Abstract Introduction

1 Departamento Exclusive breastfeeding is acknowledged as im- Exclusive breastfeeding is acknowledged as im-
de Enfermagem,
portant for survival, optimal growth, and devel- portant for survival, optimal growth and devel-
Universidade Federal do
Ceará, Fortaleza, Brazil. opment of infants. The current review presents a opment of infants in low-income countries 1.
2 School of Nursing, synthesis of research output by Brazilian nurses Numerous investigators have reported a rela-
University of Virginia
on breastfeeding over the last 20 years, analyzes tionship between breastfeeding and infant
Health Systems,
Charlottesville, U.S.A. the theoretical and methodological issues emerg- health. Such authors reveal that breastfed infants
ing from studies on breastfeeding in Brazil, and experience lower rates of acute and chronic oti-
Correspondence
provides directions for future research and prac- tis media 2, bronchiolitis 3, diarrhea 4, meningitis
D. F. Glick
School of Nursing, University tice by nurses in the area breastfeeding. Studies 5, and necrotizing enterocolitis 6, suffer less re-
of Virginia Health Systems. included in this review were identified through current wheezing 7, have higher mean IQs 8, and
P.O. Box 800782,
Charlottesville, VA,
LILACS searches of Portuguese-language sources. develop insulin-dependent diabetes mellitus
22908, U.S.A. Articles were organized and analyzed chrono- less frequently 9 than those who are bottle-fed.
dfg6x@virginia.edu logically by comparing the evolution of the Breastfeeding can also be beneficial to the
Brazilian Breastfeeding Program. The incom- mother’s health by reducing the risk of ovarian
plete research output of the Brazilian nursing cancer and bone demineralization in compari-
profession in regard to breastfeeding research son to mothers who do not breastfeed their in-
needs to be addressed. In addition, specific cul- fants 10. Women who breastfeed are less likely
tural, sociological, and anthropological charac- to develop osteoporosis and breast cancer 11,12,13
teristics of Brazilian regional settings remain to and are more prone to better social interac-
be explored. Emphasis on potential confounders tions 14. Therefore, exclusive breastfeeding has
and critical interrelations is warranted. been strongly recommended during the first
six months of the infant’s life, continued by
Breastfeeding; Nursing; Nursing Research mixed 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 to
prevent diseases in adulthood.
Over the last 20 years, Brazilian health poli-
cy has encouraged breastfeeding programs in

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

BREASTFEEDING RESEARCH BY BRAZILIAN NURSES 21

an effort to prevent early childhood illnesses Results
and to reduce infant mortality rates (IMR). For
two decades, breastfeeding campaigns have The literature searches identified 39 papers
successfully enhanced people’s commitment to published in the eight main Brazilian nursing
health promotion on a large scale. journals: Acta Paulista de Enfermagem, Cog-
The Brazilian nursing profession has played itare Enfermagem, Revista Brasileira de Enfer-
an important role in encouraging health inter- magem, Revista Gaúcha de Enfermagem, Re-
ventions in lactating mothers as a strategy to vista Latino-americana de Enfermagem, REME
improve exclusive breastfeeding rates and to – Revista Mineira de Enfermagem, Revista da
decrease early weaning. However, the real im- Escola de Enfermagem da USP, and Texto & Con-
pact of interventions by nursing teams in pre- texto-Enfermagem. We identified the number
venting early weaning and overall infant ill- of published papers according to the publica-
nesses in Brazil is not well understood. The tion date (Table 1). Among these papers, the au-
current review presents a synthesis of research thors used different study designs, as demon-
output by Brazilian nurses on breastfeeding strated in Table 2. However, for this review we
over the last 20 years, analyzes the theoretical considered only research articles ( Table 3).
and methodological issues emerging from stud- While we were organizing articles by area, we
ies on breastfeeding in Brazil, and provides di- recognized that most research output was from
rections for future nursing research and prac- Southeast Brazil (n = 15). We found no articles
tice regarding breastfeeding promotion. written in North or Central-West Brazil. In or-
der to improve the understanding of historical
trends in nursing research, we did compar-
Methods

The studies included in this review were iden-
tified through LILACS (Latin American and Table 1
Caribbean Health Sciences Literature) search-
es of Portuguese-language sources published Number of articles on breastfeeding published
since 1983, by using the following key words: by nurses in Brazil, according to publication date.
breastfeeding (aleitamento) and nursing (en-
fermagem); breastfeeding, nursing, and Brazil. Date N %
We chose the LILACS Database because it has
1983-1987 4 10.3
been the primary source of indexation for Latin
1988-1992 6 15.3
American journals. Further sources (97 refer-
1993-1997 8 20.5
ences) were located by cross-referencing, but
1998-2002 21 53.9
this review includes only papers published in
Total 39 100.0
Brazilian nursing journals by Brazilian nurses.
We excluded papers published in Brazilian and
international nursing journals that were writ-
ten in other countries and/or written by other
professionals. Books, book chapters, theses,
and dissertations were also excluded because Table 2
of the difficulty in organizing these materials
for a review. Abstracts were excluded based on Study designs in articles on breastfeeding
insufficient information to be analyzed. Arti- by authors in Brazilian nursing journals, 1983-2002.
cles were organized and analyzed chronologi-
cally by comparing the evolution of the Brazil- Design N %
ian Breastfeeding Program (BBP). A compre-
Reflection 1 2.6
hensive review and implications for future re-
Review 4 10.3
search and practices in breastfeeding by the
Report of experience 6 15.4
nursing profession are presented.
Update 7 17.9
Survey 21 53.8
Total 39 100.0


22 Oriá MOB et al.

Table 3

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

Study Location Subject Type of study Theoretical Research tools
characteristics 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 Interview
infants 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 interview
Friedlander 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 interview
same 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.

isons within the BBP timeframe, organizing our lion households nationwide 15. However, the
data according to time windows. first paper published by nurses in breastfeed-
ing research emerged in 1983 with a study by
Fadul & Xavier 16 and the second in 1986 with
First period: 1983-1987 Vale & Albuquerque 17. Both papers focused on
weaning. These authors aimed to understand
The BBP was launched in March 1981 through why mothers weaned their babies early. Fadul
a mass media campaign by television, radio, & Xavier 16 observed that 42 (70.0%) of mothers
and print media advertising, reaching 20 mil- weaned their babies before three months. Para-



doxically, mothers with more schooling weaned justified their choice based on a hospital rou-
even earlier, as follows: illiterate mothers, 4 tine in which a baby is fed every three hours.
(6.6%); mothers with complete high school, 17 While hospital routines are conducted to opti-
(28.5%). In addition, urban women (n = 38, mize the work in the hospital environment,
63.3%) were more likely to wean their babies they may not always work in the home context.
before three months as compared to rural moth- Some mothers learned and replicated these
ers (n = 4, 6.6%). practices at home because they believed that
According to Vale & Albuquerque 17 the main this model was better for feeding their babies.
causes of early weaning were: (1) pediatrician’s Silva 19 tested a systematized procedure of
advice to use formula milk; (2) suppression of nursing care for mothers with breast engorge-
breastmilk because of fear; (3) “lumping” of ment. The intervention represented a combi-
milk attributed to the baby’s burping during nation of three different techniques: massage
breastfeeding; (4) contraceptive use; (5) con- with an electric vibrator, suckling stimulus for
cern about the breasts’ appearance; (6) moth- the baby, and hand manuevers for the mam-
er’s concern about the possibility of acquiring mary glands. The combination of these tech-
illnesses due to calorie loss; and (7) prioritizing niques was termed the “Systematic Nursing
domestic tasks. Care Procedure”, applied after each feed until
Based on their findings, Vale & Albuquerque the engorgement regressed. According to her
17 strongly recommended reinforcing attitudes findings, therapeutic sessions were 4.4 times
toward breastfeeding during prenatal and pe- more common in women with glandular breast
diatric consultations (especially in the first six engorgement and resulted in a reduction in to-
months postpartum), in order to further encour- tal breast engorgement after an average of 6
age women’s adherance to exclusive breast- hours and 54 minutes for the lobar type and 11
feeding practices for a much longer period. hours for glandular breast engorgement. Re-
gression time was longer in women with low
birth weight babies and in those whose babies
Second period: 1988-1992 remained less time suckling. Nursing interven-
tion was efficient by decreasing symptoms of
In 1988, four new policies in favor of breast- breast engorgement, preventing cracked nip-
feeding practices were consolidated in Brazil, ples, and avoiding other common complica-
representing a historical turning point in the tions related to breast engorgement, in addi-
program: (1) the National Ruling on Commer- tion to promoting women’s self-care during
cialization of Infant Foods; (2) Ruling on Hu- treatment.
man Breast Milk Banks; (3) inclusion of the In another study of 92 women by Scochi et
right to a four-month maternity leave in the al. 20, 73 mothers (79.34%) were assisted at pre-
Brazilian Constitution; (4) inclusion of the natal care units. Of these, 65 (89.04%) did not
right to a five-day paternity leave in the Brazil- receive any nursing assistance related to infant
ian Constitution. care. Among the themes chosen by the re-
During this critical period of establishing searchers to evaluate educational programs,
and maintaining the first program goals, nurs- care with the umbilical cord stump was pre-
es began playing a more active role in the new ferred by the women in the study, reaching a
BBP, as shown by three articles on breastfeed- higher learning index than other items mea-
ing 18,19,20 . These studies used different de- sured at hospital admission and discharge. In
signs and focused on different themes (feed- addition, primiparous mothers showed more
ing regimens, breast engorgement, and moth- positive attitudes towards technical aspects of
er’s knowledge about breastfeeding). Neverthe- infant care. All mothers in the study showed
less, the general focus was on women’s health, willingness to breastfeed, as evaluated at both
revealing the awareness of Brazilian nurses admission and discharge. However, a possible
concerning women as important promoters bias is that the women might be more prone to
and recipients of health care during the lacta- breastfeed by convenience during hospitaliza-
tion process. tion, fearing retaliation from the health care
According to Scochi et al. 18, 85.53% (n = 65) team and failing to disclose their real decisions
of mothers interviewed offered breast milk on about intended breastfeeding practices. In ad-
a self-demand scheme, and 91.1% of their de- dition, the study was not extended to the home
cisions about breastfeeding practices were in level, so women’s knowledge and breastfeeding
accordance with proper technical procedures. practices outside the hospital remained insuf-
Among 11 (14.47%) mothers who chose to ficiently explained. Moreover, the time elapsed
breastfeed according to a rigid schedule, 33.0% between admission for normal delivery or ce-


24 Oriá MOB et al.

sarean and hospital discharge may not be suf- need to reevaluate the tool. However, the sam-
ficient to evaluate real behavioral changes in a ple was limited to post-cesarean women and
family context. thus did not consider the needs of women who
had experienced vaginal delivery. In addition,
the sample was too small (n = 12) for more con-
Third period: 1993-1997 clusive findings and was thus inappropriate to
suggest replacing the NANDA tool in regard to
In 1992, the implementation of the “Baby- breastfeeding.
Friendly Hospital Initiative” in Brazil enhanced The last study in this period was published
previous goals to fulfill “ten steps to successful by Boehs et al. 25, who analyzed the breastfeed-
breastfeeding” by highlighting the natural ad- ing experience up to the 6th month after birth
vantages of breast milk and not encouraging using interviews with mothers at 15 days and 2,
use of milk substitutes. Several hospitals were 4, and 6 months after delivery. These researchers
enrolled in this program. However, in 1996 the found that 41.3% (n = 19) of the mothers breast-
Brazilian Ministry of Health decided to add fur- fed their babies at the 6th month, but only
ther requirements for enrollment, especially 15.2% (n = 7) exclusively breastfed. In the first
focused on lowering cesarean rates and thus interview, 26.0% (n = 12) had introduced other
substantially impacting new enrollments in this foods into the baby’s diet. Causes of low exclu-
program 21. During this period, four new studies sive breastfeeding rates were grouped as fol-
were published by Brazilian nurses 22,23,24,25. lows: (1) mothers who were unable to breast-
The study by Marcon 22 highlighted the feed; (2) infants who were incapable of being
process, concepts, and women’s experiences breastfed; (3) mother’s beliefs; (4) the pediatri-
during weaning. Study participants unexpect- cian’s orientation; and (5) family influence.
edly supported an age limit for breastfeeding Such findings highlight the importance of
(≅ 1 year old). After this age, they believed that contextual and cultural factors in the decision-
breast milk would no longer provide adequate making process on breastfeeding and the fami-
nutrition. In addition, they were strongly influ- ly’s key role in supporting and influencing a
enced by their social groups toward weaning mother’s decisions. Educational programs tar-
practices, contributing to the high weaning geting these factors are critically important.
rates in this population. Difficulties in breastfeeding were more fre-
A second study by Almeida 23 addressed quent in the first interview (15th day after de-
women’s emotions during the process of early livery). By experiencing breastfeeding for the
weaning. Data revealed that breastfeeding was first time and after receiving adequate counsel-
a dynamic social practice, constantly in recon- ing from researchers about how to deal with
struction, with continous shaping and remod- common problems, mothers had become more
eling. Breastfeeding and weaning were inter- confident and were more prone to sustain
mingled with myths, misconceptions, and prej- breastfeeding.
udices based on historical and sociological
backgrounds. Women’s emotions during breast-
feeding and weaning were shown to be related Fourth period: 1998-2002
to historical momentum and ongoing educa-
tional processes. When guilt was identified as an Since 1999, the Ministry of Health has imple-
emotional component of the weaning process, mented new policies regarding milk formula,
the women began finding excuses to justify their pacifiers and baby bottles for companies, which
weaning decision and redeem themselves. The are contradictory to the National Ruling on
author found several meanings underlying the Commercialization of Infant Foods. In 2000-
weaning response, including indifference, sac- 2001 the ruling was reviewed, extended, and
rifice, guilt, pleasure, relief, and exploitation. elaborated in greater detail 21.
The third study, by Abrao et al. 24, designed We identified 12 articles published during
a model for data collection to validate the this period, two of which focused on breast-
NANDA-I (North American Nursing Diagnosis feeding 26,27. Silva 27 conducted a prospective
Association, Taxonomy I) generally used as a study to evaluate breastfeeding representation
dignostic tool in breastfeeding practices. Infor- for nursing students in order to understand
mants were provided with nursing couseling their conceptions concerning care for the moth-
on the 7th and 15th days after delivery. The au- er-infant pair during the lactation process. Ac-
thors found that among 25 nursing diagnoses cording to nursing students, the most impor-
from the instrument, only 13 (52.0%) were clear- tant meaning was “be there with the mother”,
ly identified in this population, justifying the to support and counsel mothers, an approach



they felt would result in increased breastfeed- and insufficient sleep. The data emphasized the
ing rates. Thus, from the student’s perspective, importance of regular follow-up of mother-in-
nursing care was considered more than just a fant pairs to encourage successful breastfeeding
technical issue. and promote the health of premature infants.
Pereira et al. 26 studied the relationship be- Concerned with education for first-time
tween the health model implemented under mothers, Pinelli & Friedlander 30 developed an
the Unified National Health System (SUS) and educational program based on an andragogy
current practices in a primary care center. Nurs- model, highlighting two main themes: “breast-
es reported some operational difficulties due feeding and breast care” and “newborn infant
to disagreements between the nurses’ (holistic) care”. Healthier babies and fewer maternal com-
and physicians’ (segmented) approaches. Nurs- plications were seen in the group of women
es in the study by Pereira et al. reported that who had chosen educational programs as com-
breastfeeding practices should not be separat- pared to the other group that was enrolled in
ed from the health policy context, and there- educational activities arbitrarily chosen by nurs-
fore breastfeeding promotion strategies should es. The authors highlight the need for targeted
address local needs, underpinned by profes- programs, including themes previously designed
sional availability, investment in human re- to meet the client’s own needs. According to
sources, and periodic and systematic assess- these findings, women should decide what and
ment of outcomes. how much they need to learn. Such a personal-
Harada et al. 28 aimed to identify factors as- ized group approach would require that nurses
sociated with early weaning and mixed nutri- have a wider range of technical and specialized
tion (breast milk + other milks or teas) in hos- training on breastfeeding issues, learning and
pitalized infants. These researchers suggested teaching skills to assess individual needs.
that early weaning was directly related to the Rozario & Zagonel 31 implemented interac-
mother’s lower schooling. Other factors were: tive activities in hospital rooming-in by utiliz-
“insufficient milk” (44.0%), “lack of milk” ing an educational approach. They have sug-
(35.0%), and “mother’s occupation” (8.0%). The gested more effective actions by identifying the
main causes of infant hospitalization were bron- mother’s own needs in regard to breastfeeding,
chopneumonia and pneumonia with or with- and consequently providing more personalized
out complications (71.2%) and diarrhea (27.3%). and more meaningful holistic care.
During the review, we identified only one In a series of three publications, Nakano
study focusing on premature newborns 29, high- and colleagues discuss issues in the decision-
lighting nursing care in human breast milk making process, breastfeeding practices, and
banks (HBMB), a practice which has played a women’s right to breastfeed 32,33,34. The authors
significant role in increasing weight gain in studied breastfeeding practices from a female
premature newborns after hospital discharge. perspective and suggested that breastfeeding
This study followed 300 infants every 72 hours represents a feminine prototype to socially qual-
until they began gaining weight (18g/day or ify for women’s role in society 33. In addition,
125g/week). In the first assessment, only 33 according to these researchers, women suffer
(11.0%) infants showed higher weight than be- from ambivalence between self-adjustment
fore hospital discharge. However, other infants (obligation, giving, and sacrifice) and resistance
enrolled in this study exhibited insufficient (physiological inability to breastfeed). This con-
weight gain (24.0%) and even weight loss flict causes more distress and frustration due
(65.0%). Nursing care in HBMBs during the to their inability to sustain “a model of ideal-
second assessment was critical for improved ized motherhood” required by the social group.
weight gain in that group, with only 5.1% pre- Machado et al. 32 identify three important
senting weight loss. Among premature infants components in the decision-making process
showing weight loss or insufficient gain, sever- on breastfeeding: family, health professionals,
al factors were associated with these outcomes, and the media. In regard to family issues, these
including cultural influences, specifically taboos researchers found a beneficial role in the hus-
and beliefs such as “weak milk” and “small band/father. Family factors can positively in-
amount of milk”. In addition, the authors re- fluence the decision-making process on breast-
ported other important factors such as the feeding. In regard to professional care, a major
need to complement the infant’s diet with wa- concern was the importance of appropriate
ter and tea, uncertainty about breast milk qual- maneuvering to breastfeed, revealing a prefer-
ity, incorrect breast maneuvers during suck- ence for a biological approach in nursing. In
ling, stress, inadequate management of the addition, these authors emphasize the advan-
breast before, during, and after breastfeeding, tages of technical education to encourage lac-


26 Oriá MOB et al.

tating woman. Lastly, the media was important ening bonds and creating opportunities for
for women’s understanding of the advantages self-expression and questioning. Based on these
of breast milk. findings, the authors suggest a complete nurs-
In the last study of the series, Nakano & ing follow-up at least during the first steps of
Mamede 34 analyzed the social environment in breastfeeding. This nursing support aims to
which Brazilian women are immersed during avoid frustration, difficulties, and behavioral
breastfeeding, focusing on female employees. errors which could jeopardize the early breast-
The authors highlight a Brazilian national law feeding process and ultimately facilitate early
granting a 120-day leave for women to breast- weaning.
feed at home. They explored the model’s feasi- Abrao et al. 37 recently conducted a descrip-
bility, which does not currently cover women tive and analytical study enrolling 181 women
in the informal labor market, apart from the to clinically validate the key characteristics of
law’s benefits. In addition, even for women effective breastfeeding diagnosis under NAN-
who are likely to be granted these 120 days at DA-I. The authors validated 5 constant charac-
home, at the end of the breastfeeding leave teristics: (1) the child’s ability to find the nipple
they are unable to continue breastfeeding be- and areola; (2) signs and/or symptoms of oxy-
cause of the scarcity of daycare centers near tocin release; (3) regular and sustained suck-
their places of work. In turn, this 120-day em- ling/swallowing at the breast; (4) infant con-
ployment leave to breastfeed changes women’s tentment after feeding; and (5) normal bowel
behavior and promotes a more flexible role as movement patterns for age.
spouse, mother, and employee, whereby women
tend towards household and spousal roles, de-
clining to play a productive role in society. This Discussion
restriction to household life can have a tremen-
dously negative impact on family income, be- Based on a historical overview of nursing re-
sides increased dependency on the husband. search on breastfeeding practices in Brazil, we
These researchers identified the importance of have identified growing research interest in
nursing care to promote breastfeeding, not on- breastfeeding outcomes related to recommen-
ly biologically, but also in assisting women dations by the Brazilian Breastfeeding Program.
within their historical social context. The research approach was based on a women’s
Ichisato & Schimo 35 conducted a study health perspective rather than a more varied
with three women from the same family in dif- point of view such as the family context or oth-
ferent generations (mother/daughter/grand- er health paradigms, including structural and
daughter) in order to analyze feeding traditions operational issues and local policies. Only one
during breastfeeding. These investigators high- article published in Brazilian nursing journals
lighted that breastfeeding is not only a biologi- directly addressed the benefits of breastfeed-
cal issue, but also historical, sociological, and ing for child care 29.
psychological. It can be heavily influenced by Most of the papers used a qualitative ap-
culture, beliefs, and philosophical concep- proach to examine the benefits of breastfeed-
tions, which in turn can take the form of a so- ing. Few studies used quantitative data to eval-
cio-cultural legacy elaborated through distinct uate independent variables about successful
family meanings in the woman’s world. This breastfeeding rates. Surprisingly, no studies
behavior was clearly evidenced when mothers used more rigorous statistical analyses, such as
started using milk secretion stimulants (from multilinear regression models and multivariate
regional galactogogue sources), which were correlations as the basis for more powerful
mainly chosen through mother-to-daughter findings. Additionally, some aspects of ecology
communication in situations of hypogalactia. and environmental relationships are still fre-
The women usually try a variety of fruits, juices, quently understimated. The scarcity of quanti-
fish, poultry, milk, cheese, tea, and chicken tative research limits the portrayal of intercon-
soup of dubious pharmacological benefit be- textual and intracontextual relationships be-
fore seeking professional aid. tween different variables. The lack of studies
Oscar et al. 36 conducted a qualitative study that acknowledged potential confounding fac-
on meanings ascribed by lactating women af- tors or employed more refined research de-
ter breastfeeding counseling. These authors signs underline the significant need for more
identified that nursing counseling helped to rigorous research by the nursing profession on
foster behaviors involving comfort and confi- breastfeeding in Brazil.
dence during breastfeeding and better relation- Among the 21 articles reviewed, only seven
ships between mother-child pairs by strength- were supported by a theoretical framework.



Theories were diversified and sometimes can actively encourage breastfeeding practices
broadly assessed. Importantly, no studies cen- by being more accessible to local communities
tered on culturally dynamic subjects by using and offering technical and emotional support
ethnography and ethno-nursing. We empha- for new mothers. Nurses can identify the cul-
size the importance of the cultural approach tural and family issues related to prevalent be-
for nursing research because of the socio-cul- haviors.
tural peculiarities of each Brazilian region. Ac- In short, we found a lack of consistent nurs-
cordingly, it is critical to shape novel BBP ing data from the North and Northeast regions
strategies that are appropriate for regional cir- of Brazil. Peculiar cultural, sociological, and
cumstances in order to fulfill local health pri- anthropological characteristics of Brazilian re-
orities. gional settings remain to be explored. Empha-
Appropriate health information is especial- sis on potential confounders and critical inter-
ly important for primigravid women and moth- relationships will enhance the validity of re-
ers who have experienced previous problems search outcomes. The lack of continued stud-
with breastfeeding. It has been shown that ies in the nursing field has resulted in a knowl-
highlighting the advantages of breastfeeding edge gap in theoretical and nursing practices
for the child and mother and providing techni- in various areas, especially those with the great-
cal and material support for breast preparation est needs. The unfinished task of the Brazilian
is not sufficient to successfully increase breast- nursing profession in regard to breastfeeding
feeding rates. Women need to receive special research needs to be addressed urgently in or-
nursing assistance and appropriate cultural der to creatively and efficiently gather and
care in local communities in order to interrupt manage relevant public health data aimed at
an unhealthy behavioral cycle and define new planning appropriate intervention strategies.
health attitudes and concepts. Brazilian nurses

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Final version resubmitted on 20/Aug/2004
Approved on 24/Aug/2004


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