Contribution of Family Nurses to the Success of Breastfeeding

Introduction: Breast milk is extremely important for maternal and child health bringing indisputable beneﬁts to mother, family and society. Health professionals, including nurses, play a key role in promoting and supporting breastfeeding with all their technical-scientiﬁc knowledge and proximity to the population. Aims: Understand the mothers' perspective regarding the contribution of health professionals to the success of breastfeeding. Methodology: Qualitative study with a phenomenological approach. Semi-structured interviews were conducted with 13 women from a Family Health Unit in a Primary care setting who were mothers between December 2016 and December 2017. A content analysis of the data was performed with the support of web-based data analysis (webQDA®) software. Results: The intervention of the family nurse in the context of pregnancy surveillance and child health consultations is distinguished, as well as in home visitation. The intervention of midwives in pre-natal courses and post-natal breastfeeding consultations also demonstrated to be relevant for breastfeeding success. Conclusion: As recommended by the World Health Organization and United Nations International Children's Emergency Fund, an effort is being made by health professionals, including nurses and midwives, for support of mothers and families in the decision, establishment and maintenance of the breastfeeding process, contributing positively to its success and establishing a follow-up to woman and family throughout the pregnancy-puerperal cycle.


Introduction
Breast milk has indisputable benefits for health promotion and disease prevention in children, mothers, families and inherently for the entire population. The World Health Organization (WHO) and the United Nations Children's Fund (UNICEF) issue recommendations with the aim of promoting, encouraging and supporting breastfeeding. These recommendations propose the establishing of breastfeeding in the first hour of life, exclusively up to 6 months and from then on, fed safe and adequate complementary foods while continuing breastfeeding for up to 2 years and beyond 1 .
It appears that health professionals assume a normalizing and regulating role in breastfeeding practices. Nurses stand out constituting an essential resource in breastfeeding, given their specific training and proximity to the population, thus contributing positively for pregnant women / mothers to breastfeed. The intervention of the nurse occurs throughout the pregnancy delivery and postpartum period and should be focused on the family, which is a conditioning element for this practice 2,3,4 .
Family nurses emerge as an important intervenient for the promotion and support for breastfeeding, contributing to its success as they work within a health care team, are familiar with the family´s members, dynamics, function as well as health and social context. Thus, they are able to intervene and contribute to the empowerment of the families in issues related to breastfeeding, improving breastfeeding rates 5,6 .
Scientific evidence refers that information about breastfeeding received during pregnancy consultations and in courses for preparation for childbirth are crucial to successfully overcome the obstacles that arise during the puerperium period 3,7 . Similarly, postpartum follow-up, a er hospital discharge, is also determinant for the success of breastfeeding, because hospital stay is short and woman may not apprehend all the information transmitted by nurses in this context because they are focused on the child. So follow-up performed in a Primary Health Care (PHC) setting is important 8,9 . Bearing in mind the importance of breastfeeding, the need to promote it according to the WHO guidelines, the relevance of the family health nurses in this process, as well as the scarcity of studies in this matter, arose the necessity to study the contribution of family health nurses to the success of breastfeeding from the women's perspective.
An empirical study was conducted to understand the mothers' perspectives on the contribution of family nurses and other health professionals to the success of breastfeeding. To this end, the experiences of women users of a Family Health Unit (FHU) in a PHC setting in Portugal, who were mothers between December 2016 and December 2017 were explored through a qualitative paradigm with a phenomenological approach, having used the semi-structured interview as a data collection tool.
The study aimed to understand the perspective of mothers regarding the contribution of family nurses and other health professionals to the success of breastfeeding.

Methodology
A qualitative type of study was chosen because it was showed to be the most appropriate to understand the contribution of family nurses and other health professionals to the success of breastfeeding 10 .
The study included 13 participants, who were women who attended the child health surveillance consultations at FHU in a PHC setting in the Central region of Portugal named "USF Leme", between October 2018 and January 2019. The women who joined the study were invited to participate during child health surveillance consultations, taking into account the inclusion criteria: being a mother in the period between December 2016 and December 2017, being a user of the FHU, being over 18 years old and being able to respond to the interview. The period defined for the birth of the children was based on the opo o to breastfeed.
The research question was: Does family nurses or other health care professionals support contribute to successful breastfeeding?
The objectives were: -Identify the mothers' perceptions of the support received by the family nurse and other health care professionals regarding breastfeeding; -Identify the contribution of the support received by family nurses and other health care professionals to the success of breastfeeding; Contribution of Family Nurses to the Success of Breastfeeding -Identify the importance assigned by mothers to the contribution of family nurses and other health care professionals to the mothers' decision to continue breastfeeding.
To collect data, a semi-structured interview was used and consisted of two parts. The first part refers to a brief sociodemographic and clinical identification of the participants (Gra ar scale) and the second was the interview guide that consisted of questions that met the objectives outlined for the study.
For data analysis, content analysis was used using the web-based data analysis (webQDA®) so ware and based on the theoretical assumptions of Bardin and Amado 11,12 . The coding of the data followed a logic "tree" structure with di erent branches, called dimensions 11,12,13 , which were subdivided into categories and sub-categories ( Figure 1).
The ethical principles contemplated in the Nuremberg Code, the Declaration of Helsinki and the Belmont Report were guaranteed through the participants' complete previous informed consent, anonymity and confidentiality. The interviews were conducted in a quiet and private environment (FHU o ce).

Results
In coding the dimension Breastfeeding: women's experiences, emerged the category Factors influencing breastfeeding, from which the following subcategories emerged: professional support during pregnancy (preparation classes for childbirth and pregnancy surveillance consultations) childbirth and immediate postpartum and postpartum (child health surveillance consultations, home visitation, breastfeeding counsellor and telephone consultation.
Breastfeeding is a complex process conditioned by several factors, in which the professional support was pointed out women. Regarding professional support, nurses are mentioned in all interviews as support agents in the breastfeeding process.
"I think nurses are important for breastfeeding support, because I even witnessed in the hospital, not this time, but the other time, situations of mothers who did not want to breastfeed, and if it were not for the nurses, they would not breastfeed at all...at all!" (E6) "I think, without a doubt, that the nurses were most important (...) When help was needed, I had it promptly!" (E4) As for the professional support provided during pregnancy, two moments of professional support were recognized in the interviews, namely: in childbirth preparation classes and the pregnancy surveillance consultations.
Not all mothers attended the childbirth preparation classes, because they already had previous experience and did not feel the need of it, or because of lack of opportunity. For those who did attend these classes, the opinions were positive and it was evident in the reports that these classes are important resource for the success of breastfeeding, because they provide the acquisition of competencies that are essential for the breastfeeding process. One mother reported that   "I received support to be successful in breastfeeding, maybe in the classes with the nurse in the prenatal classes!" (E5) Regarding pregnancy surveillance consultations, most mothers had their appointments in the PHC setting and mentioned the importance of the family nurse. The family nurse played an important educational role, providing breastfeeding counselling, transmitting information orally and supporting information in paper format.
"Even here the family nurse always gave me advice! In the first consultations, I was told about breastfeeding!" (E1) "The family nurse also talked to me about breastfeeding during pregnancy! She provided some flyers!" (E5) Due to high-risk pregnancies, two mothers had their pregnancy monitored in a hospital setting and reported that the breastfeeding education was provided through written information (handouts, flyers or posters) no direct education and encouragement was received from health professionals.
"My appointments were basically all in Aveiro because of gestational diabetes. And basically, I had more consultations there than here. And they didn't talk much about breastfeeding! They would give the flyers but it wasn't the same thing as talking directly to the person." (E3) "I was followed in the hospital...I would see the boards with the news and information!" (E4) As for the professional support at the time of childbirth and postpartum, nurses were again highlighted as the professionals who were most present and who provided the most support for breastfeeding, accompanying the woman in order to promote breastfeeding and its optimization. There are reports that describe that doctors were also present, but it was the nurses who provided the follow-up and support for breastfeeding. The professional support provided in the postpartum period was identified in three distinctive moments: during child health surveillance consultations, Health professionals home visitation and the telephone consultations. In this context, the intervention of the family nurse was highlighted.
"I think the family nurse was the only person...to help, to support, to give advice!" (E10) Mothers mentioned the importance of the family nurse role for breastfeeding support during child health surveillance consultations, through the follow-up and monitoring of the baby's weight gain and assessing parents on the baby´s elimination (urination and defecation), among other aspects related to adequate breastfeeding.
Mothers acknowledged the trustworthy relationship and partnership with the family health nurse, and expressed greater tranquillity with the clarification of doubts and the support provided. As for the postpartum home visitation, all mothers who had them revealed that it had great benefits and certainly an added value. Reports from mothers revealed that this visit enabled the provision of care to the woman at home, given the proximity of the childbirth and her debilitating condition, which facilitated her postpartum recovery process and provided greater convenience for the mother, newborn, and family. The mothers also revealed that this visit allowed a realistic acknowledgement of their living conditions and a greater proximity to the family. Breastfeeding assessment is facilitated, mother-child relationship can be observed in a real-life context through home visitation. The telephone consultation was also used by two mothers for breastfeeding assistance, receiving support from the family health nurse.

"The home visitation was also impeccable! At the time of the A, I didn't have it either...And I think it's an advantage!" (E5
"I called the health center, for example, and the nurse always informed me about situations that I needed. I felt accompanied, yes!" (E9) "I never had the need, but by phone I cleared up a lot of doubts!" (E13) Breastfeeding support from a Midwife and Breastfeeding Counsellor was also reported. For one mother this support was essential and crucial given that at the time of birth the hospital nurses were on strike.
"I got great support from the midwife who is a breastfeeding counsellor here at the health centre and gives prenatal and postnatal classes. It was a great help, because in the beginning, in hospital the nurses were on strike so all I had was some advice. On discharge I received support from the Midwife who was also a breastfeeding counsellor... At then I was at the point of giving up...the father already wanted to buy artificial milk… She was wonderful! (...) The Midwife, breastfeeding counsellor was what helped me!" (E13)

Discussion
In this study, several factors influencing breastfeeding were identified, congruent with those present in the literature review.

... the Professional Support
Professional support was a positive determining factor for the decision, establishment, and maintenance of breastfeeding 14,15 . This professional support is represented in the study by nurses, and it is evident through the analysis of the narratives that they accompany the woman throughout the pregnancy-puerperal cycle 16,17 .
Mothers highlighted the nurses' support during hospitalization in the postpartum period, in the maternity ward, but also at the PHC level, namely in the pregnancy surveillance consultations, postpartum and child health surveillance consultations, home visitation, telephone consultation, childbirth preparation classes, and postnatal classes. The importance of the family health nurse´s support in the di erent stages of the breastfeeding process was emphasized, and it should be considered as a relevant professional in breastfeeding support 18 . Regarding the support provided during pregnancy, the mothers who had consultations with the family health nurse show their support as consistent, while those who didn't have this type of consultation expressed less support. This fact seems to be related to the trust and empathy relationship that the family health nurse is able to establish, since he knows the woman, her family and her context 19 .
Di erent nursing interventions were noted to promote of breastfeeding success, such as emotional encouragement, health education through face-to-face direct counselling, written information through flyers and hand-outs, so women can later on Contribution of Family Nurses to the Success of Breastfeeding read and better acquire information. It is evident in the narratives that the support provided in the prenatal period contributes to a more consolidated and consistent breastfeeding process 3,7 .
As of the support provided by midwifes in the childbirth preparation (pre-natal) classes, it was described as relevantly important for most mothers. The emotional support and sense of satisfaction expressed, when breastfeeding is supported by midwives is evident in the statements 6 .
Regarding the support given by nurses during childbirth and the immediate postpartum period, these are referred to as important in hands-on teaching breastfeeding techniques, carrying out surveillance of women during this process, clarifying doubts and correcting possible set-backs, therefore contributing to the establishment of breastfeeding 15 .
In follow-up a er hospital discharge the following emerged: support through child health surveillance consultations, home health visits, telephone consultation, and the intervention of a breastfeeding counsellor. In child health surveillance consultations , the family health nurse monitors the baby's weight gain, focuses education in infant care, and in particular the signs that reveal a well fed baby as well as normal and healthy development which is found in literature to contribute to breastfeeding success 16,20 . The home health postpartum visits for mothers and newborn also emerged as an important intervention in this period that contributes to breastfeeding success, because it promotes the continuity of care, permits nurses to observe breastfeeding, interaction between mother and child in its real context, detecting di culties in child care and the convenience of not having to travel to health services 6,20,21,22 . The telephone consultation is easy and accessible for clarifying doubts, and it was noticeable that mothers were informed about this type of support, especially in the postpartum period, which is one of the strategies for maintaining breastfeeding, especially a er returning to work 16,23 .

Conclusion
Breastfeeding is considered important for most mothers, and all the women interviewed were motivated to breastfeed. Despite the di culties, mothers were mostly persistent in maintaining breastfeeding.
The support from health professionals is shown to be a determining factor for breastfeeding success.
Among the health professionals, nurses were the ones identified as the support for women throughout the breastfeeding process. Within this scope, nurses from di erent areas were acknowledged, in particular family health nurses, midwives (in prenatal classes, labour and delivery, postnatal classes, and those who are also breastfeeding counsellors), the postpartum nurse, and the hospital nurse in the high-risk pregnancy follow-up consultation. The intervention of the family nurse was highlighted in the follow-up of women during the pregnancy surveillance consultations and in the postpartum period, namely in the home health visits and in the child health surveillance consultations.
It is possible to conclude that as recommended by the WHO/UNICEF, great e ort is being made by health professionals, notably by nurses, to promote breastfeeding, to maintain it and to ensure its success. It is found that breastfeeding is focused with woman/family throughout their pregnancy-puerperal cycle.
It is also concluded that nurses are the health professionals that most support women in the process of breastfeeding throughout their pregnancy-puerperal cycle, so it up most important that all nurses who provide care should have up to date knowledge in the field.
Among the limitations of the study, it is identified that the interviews occurred in one specific FHU, which makes the population's characteristics somewhat homogeneous in terms of lifestyles, beliefs and values, as well as their experiences, since the health professionals who provide care also belong to the same health care setting.