A Cavalcante de, L Neto David, V Ribeiro de, V Lucena de, B da Silva
breastfeeding, early weaning, nursing diagnosis, risk
A Cavalcante de, L Neto David, V Ribeiro de, V Lucena de, B da Silva. Risk For Ineffective Breastfeeding: An Ethnographic Report. The Internet Journal of Advanced Nursing Practice. 2004 Volume 7 Number 2.
The research was organized as a cross-sectional study with qualitative approach through ethnographic methodology. It was conducted to identify the phenomena that can interfere in the breastfeeding. Interrupted Breastfeeding was adopted as a nursing diagnosis by NANDA in 1990. The purpose of the study was to increase the usefulness of this diagnosis by developing a new nomenclature related with a new definition by revising and testing, from a client perspective, a list of risk factors. Risk for ineffective breastfeeding was defined like this: a situation in which the mother and her baby deal with negatives experiences in the breastfeeding process by influence of biological, psychological, economical and social risk factors.
Breastfeeding is in decline world wide and depends on the local customs. The social and economic progress has provided an inverse reason regarding to breastfeeding1,2,3,4
The Brazilian government initiated in 1981 the National Program of Incentive to the Maternal Breastfeeding with the objective of changing the early weaning high index in the country. Considering that internal projects do not resolve this question, international and national agencies have committed in uncovering this situation that afflicts the Brazilian mothers5,6,7,8,9.
Some studies about breastfeeding have not only shown advantages of this practice, but as well some difficulties regarding early weaning due to factors diversified which interfere in this process10,11,12,13,14,15.
Breastfeeding is an active process which requires two participants: mother and her baby. This process is a personal choice and can't be induced by parents, friends, doctors, nurses, husband or other people. It is a personal decision that a woman makes according her needs such as biological, psychological, social and economical14,15,16,17,18.
In the last decade,s the social and economic factors has influenced and determined changes in the life of mothers and their babies. Women and infants in developing countries have been also the most vulnerable to problems caused by illnesses that weakend them and consequently prevented them from breastfeed, often causing death19,20.
Statistical studies reveal that even being objects of the sanitary vigilance, mothers and infants are not being watched properly by the Integral Aid Programs at Woman Health (PAISM), and Integral Aid Programs at Infant Health (PAISC). WHO Committee Experts in the Mother and Infant Health uncovered that social and economic factors such as the wife participation in the work, maternal malnutrition, inefficient assistencials programs, as well as lack of education in health were important in trials of breastfeeding5,6.
These risk factors demonstrate the importance of a nurse. Steele21 affirmed:
Another factor that can influence the early weaning is the introduction of artificial milk. Experts about breastfeeding designate that main reason for the use of such foods are the own mother's relatives. In the majority of the times those factors are related to the family structure whose mother is breastfeeding. According to Renfrew et al22
Genetic factors are also a problem in early weaning. The baby's birth with a defect or disorder is a traumatic event with the potential for either total disruption or growth of the involved family. Congenital problems in feeding may be result from diseases such as Pierre Robin Syndrome, Cleft Lip and Palate, or Choanal Atresia24.
In the literature, the etiology of the Pierre Robin Syndrome isn't clearly understood. It may be transmitted by a dominant gene with variable expressivity, or it may be the result of polygenic or multifactorial inheritance23. Several factors seem to be responsible for Cleft Lip and Palate. Polygenic inheritance and interaction between genetic and environmental factors (fetal viral infection, radiation, hypoxia and teratogenic insult of drugs during the lather part of the first trimester of pregnancy) may be the great responsible for malformation24.
In the United States, research has indicated some women that suffer from postpartum depression may be a great problem for the early weaning. A meta-analysis research revealed that patients with postpartum depression present with characteristics of anxiety, concentration impairments, and depressive mood “
Ziemer, Cooper, Pigeon26 evaluated the use of a polyethylene film dressing to reduce nipple pain, concluded that nipple pain is a substantial problem among breastfeeding due to occurrence of erythema, eschar formation, and skin fissures. Their study provided a reduction the nipple pain with use of an occlusive film but had limited influence on other observed factors.
In the last decades, Montessoro, Blixen27 inferred that economics factors had a growing influence in the pregnancy and childbirth. For these authors the “United States has no coherent policy on this issue resulting in confusion over exactly what the poverty problem is 28.
A cohort study, descriptive and exploratory, using a qualitative approach through ethnographic methodology, was conducted to identify the phenomena that can interfere with breastfeeding. They were described as internal and external determinants factors of the early weaning.
The study purpose was to increase the usefulness of the diagnosis Interrupted Breastfeeding that was adopted as a nursing diagnosis by NANDA29 in 1990, by developing a new nomenclature related with a new definition by revising and testing, from a client perspective, resulting in a list of risk factors. Data were collected through a case study carried out with postpartum patients through six visits at home.
Using the steps for concept analysis outlined by Bardin30 a conceptual framework was created.
A housewife, 18 years old, single woman, medium stature, illiterate, low-income woman was studied. She lived in a booth of canvas, given up by the army, in the highway BR-101 margins in João Pessoa city/Paraíba/Brazil's Northeast. The town was previously was flooded after a strong rain.
In the first visits at home the client was in the eighth month of pregnancy. She informed to us that she wasn't registered in a prenatal program, justifying that in the neighborhood there wasn't any prenatal service. In this first contact, she was anxious, nervous, scared and insecure; therefore she didn't relate to us any new fact about the care of her baby, mainly correlating her situational crisis: hungry, misery and homelessness.
On the second day of the visits, she showed a considerable emotional equilibrium, presenting less tense and more opened to the dialogue.
During the third day, she was in the postpartum and informed for us that the delivery had occurred in the maternity. It was an operative delivery and had didn't receive any orientation regarding the surgery and anesthesia or if her baby would be with her in the joint lodging. According her statements, related for us:
When we asked her about the baby's food, immediately she said us that she had introduced the artificial milk, affirming:
“My breasts are painful enough and I don't get breastfeed my baby and she cries hungry [...] both my breasts are opened [...] every time get in some people here for buying some merchandise and I'm shamed a lot of showing my breasts”.
During the forth day, we observed that the difficulties for the breastfeeding persited, therefore in her statement she argued for us:
“My breast milk is too little, the baby isn't satisfied. At night she cries a lot and I can't sleep. At sunrise I don't get to sleep (...) the noise in the trail, the heat (...) I'm so tired! Yesterday I was so nervous that I shouted with my baby and immediately my husband spanked me [...] I'm hungry a lot because I am breastfeeding [...] I feel a hole here in my stomach. My sister-in-law said to me I was going to get sick with this foolish of breastfeeding because she fed their three boys with cow milk and flour”.
During the fifth visit at her home, in the twentieth day of puerperium, she informed us that her baby had been hospitalized because she had an abscess in the left eye. She wouldn't be with her baby in the hospital after surgery and wouldn't be able to stand by in the hospital for a long time indicating that the hospital unit wouldn't offer conditions for resting or to give her some foods. At this occasion the client complained to us of breasts engorgement.
During the sixth and last day of visits at home, we detected that the baby still was hospitalized with a diagniosis of pneumonia. The baby remained hospitalized for fifteen days and returning to live with her mother after this episode. She didn't breastfeed anymore, being introduced definitely the artificial milk for her baby.
Risk For ineffective Breastfeeding was defined like this:
Based on information analysis, it was determined that there are two attributes for validating the content and the construct of Risk For Ineffective Breastfeeding: For this study, the two critical attributes must be presented before determining the diagnosis of Risk for Ineffective Breastfeeding:
A relationship that exists between the client and the factors of risk environmental external and,
The client has experienced ineffective breastfeeding caused by one or more negative situation in their life or impaired life-style.
Additional studies should be done using expert nurses selected systematically from an interest's group of Risk For Ineffective Breastfeeding to identify and to validate others factors of risk.
Araújo Ednaldo Cavalcante de, PhD, RN. Nursing School. Federal University of Pernambuco/Brazil's Northeast. firstname.lastname@example.org Address: Rua: Severino Nicolau de Melo, 582 - Edifício Ilha da Restinga, Ap. 904-b - CEP: 58036-260 – Bessa – João Pessoa (PB) – Northeast of the Brazil