Medical and psychological aspects of breastfeeding

Promoting and supporting breastfeeding is a global priority and an important intervention for the survival of children. The World Health Organization and the American Academy of Pediatrics recommend exclusive breastfeeding in the first six months of life. This article propose a review of the most important medical and psychological aspects regarding psychological counseling and breastfeeding. We highlighted the results of studies that reflect the importance of breastfeeding and its effects on the baby and mother. This paper is a review based on information from the literature. The analysis was limited to articles and guides in English published between January 1, 2007 - June 1, 2021 on PubMed, ScienceDirect and Google Scholar using the following keywords: breastfeeding, mother-child breastfeeding breastfeeding. In this review we discuss the medical and psychological characteristics of breastfeeding, factors that determine exclusive breastfeeding and its effects, prenatal breastfeeding counseling and the role of psychological counseling in initiating and maintaining breastfeeding. Psychological counseling and care practices influence the achievement and duration of breastfeeding.


BACKGROUND
In the scientific literature, studies on counseling and therapy of expectant mothers have as therapeutic objectives the following: interventions to stop substance use and tobacco use, interventions to monitor body weight and prevent overweight, counseling to prevent the risk of childbirth premature and breastfeeding counseling [1].
This review highlights the most important medical and psychological aspects which allows the identifica-tion of methods, techniques and counseling programs in which expectant mothers learn how to relax in the prenatal stage, to relax physically and mentally, to activate their maternal resources, to become available to the fetus, to increase their self-confidence, to be aware of the important role of breastfeeding in the first six months of life and to be very well informed about the technical aspects of this period.
Before making a synthesis of the literature on the role of breastfeeding counseling in initiating and maintaining breastfeeding, we consider important to under-stand this phenomenon, as well as the factors that determine exclusive breastfeeding and its effects.
Alzaheb [2] identified in a complex systematic review the most important factors that triggered the process of breastfeeding one hour after birth and the maintenance of exclusive breastfeeding in the first six months postpartum. Among the categories of factors that are associated with the initiation of breastfeeding are: type of birth, commitment to work, the room of the institution where the woman gave birth, parity, breastfeeding.
Seven out of eight studies that explored the relationship between birth type and the initiation of breastfeeding found that cesarean delivery is a risk factor, which leads to inhibition of breastfeeding behavior in the first hour after birth. Also, most studies have shown that working mothers postpone the start of breastfeeding. An interesting aspect is the room in which women stay after giving birth. Thus, it was found that there is a positive correlation between staying in the same room with the newborn and initiating breastfeeding.
Other factors associated with the initiation of breastfeeding are: residence, family planning, history of breastfeeding, educational level of the father, sex of the child, weight of the child, feeding during the night.
In the category of factors associated with exclusive breastfeeding we can list: the mother's educational level, commitment at work, mother's age, type of birth.
To the factors presented by Alzaheb [2] can be added those indicated by Wallenborn et al. [3], such as: the support of the father, the support of other pregnant women, the desire to have the child. Regarding the last factor, the desire to have children, the authors found that one partner wants the child and the other does not want it is associated with low percentages in initiating breastfeeding, delayed prenatal care, increased consumption of tobacco in pregnancy and high percentages of premature birth.
Regarding the effects of breastfeeding on the baby, Wallenborn et al. [3] showed that it causes lower rates of upper respiratory tract infections, otitis and enterocolitis. Breastfeeding is also helpful in lowering the rate of obesity, asthma and tooth decay in children. Similarly, breastfeeding has benefits for the mother's health. It improves sleep quality and feelings of maternal well-being, and breastfeeding is associated with a lower risk of ovarian cancer and breast cancer, a lower risk of type 2 diabetes, and an earlier return to pre-pregnancy weight.
Another factor for breastfeeding often explored in research is premature birth. Thus, in a recent study Lok Fan et al. [4] considers that compared to normal birth (39 to 42 weeks), premature birth (37 to 39 weeks) is associated with adverse neonatal outcomes that may prevent breastfeeding.

PSYCHOLOGICAL COUNSELING AND BREASFEEDING
Promoting and supporting breastfeeding is a global priority and an important intervention for the survival of children. However, in reality, many mothers are not able to practice exclusive breastfeeding, as claimed by the World Health Organization (WHO) [5]. The World Health Organization and the American Academy of Pediatrics recommend exclusive breastfeeding in the first six months of life [5,6].
Breastfeeding counseling [7] and care practices influence the achievement and duration of breastfeeding.
Prenatal breastfeeding counseling aims to increase the knowledge and practical skills regarding breast- Federal activities in support of breastfeeding [10] feeding techniques that prepare mothers for possible future difficulties. Most preventive interventions to encourage breastfeeding are done by specially trained nurses [8].
Prenatal counseling helps mothers to be motivated for exclusive breastfeeding for a period of six months immediately after birth. All pregnant women should be informed about the benefits and management of exclusively breastfeeding as a matter of priority during antenatal consultations [9].
Olenick [11] conducted a study in which he showed that self-confidence in breastfeeding determines the exclusive breastfeeding of the baby. An important point to note is that mothers' confidence in breastfeeding has been studied more in the postnatal stage and there are very few studies in the prenatal period.
Yurtsul and Kocoglu [12] conducted a study on prenatal counseling methods for both parents between the last trimester of pregnancy and six months postpartum on the breastfeeding process and maternal and paternal attachment. The study sample consists of 76 pregnant women and their husbands. The authors used numerous assessment tools to measure aspects of breastfeeding, self-confidence, maternal and paternal attachment. The use of these tools provides a concise view of the effects of prenatal counseling on the breastfeeding and the mother-child and father-child relationship.
The counseling procedure involves visits to the hospital, home, and telephone interviews. Thus, the experimental group received two hospital visits, six home visits and four telephone interviews, while the control group received a hospital visit after birth in which questionnaires with items about the roles of mother and father, postnatal period, breastfeeding characteristics and the breastfeeding time and daily frequency. When the babies were six months old, the parents answered in a telephone interview questions about self-confidence regarding breastfeeding, the breastfeeding time and daily frequency, maternal attachment, paternal attachment and breastfeeding characteristics.
The results indicate that the mothers in the experimental group had more knowledge and a positive attitude regarding the variables related to breastfeeding. At the same time, the results show that there are significant differences between the two groups (p < 0.05) when all variables were taken into account, namely: the duration of exclusive breastfeeding, the age at which the baby was breastfed, prenatal breastfeeding counseling, the initiative to breastfeed, the duration of each breastfeeding, the benefits of breastfeeding for the baby, the benefits for mothers, the use of a pacifier, discussions with the husband about breastfeeding.
All these results are in line with the idea that breastfeeding counseling should start in the prenatal period.
Pregnant women should be informed about the benefits and methods of breastfeeding [13]. Several studies claim that prenatal breastfeeding preparation leads to exclusive breastfeeding [14][15][16]. Research also shows that counseling sessions with expectant fathers increase the rate of initiating and maintaining breastfeeding in the first six months [17,18].
Similar results were obtained by Mikami et al. [19] who explored the effects of prenatal counseling on breastfeeding in women giving birth to twins. The study sample consisted of 171 mothers and their 342 infants. Participants were randomly divided into the group that performed prenatal counseling sessions and the control group. Breastfeeding data were collected through personal interviews in three stages after birth: 30 to 40 days (Period 1), 90 days (Period 2) and 180 days (Period 3).
There are several studies in the literature that use cognitive counseling as an effective method of psychological counseling for breastfeeding. Thus, after participating in a cognitive counseling session, women scored higher on a scale that measured breastfeeding levels and identified mothers at risk of failure in exclusive breastfeeding [20].
In Romania, there are very few studies to explore the effects of prenatal counseling on breastfeeding. However, this issue is present in the reality of the country and thus several organizations have been formed that support and provide advice to future parents and current parents regarding breastfeeding.
A national study, conducted by the Association of Maternal and Infant Health (SAMAS) [21] together with "Alessandrescu-Rusescu" National Institute for Maternal and Child Care and the National Society of Family Medicine, shows that more and more mothers in Romania follow the World Health Organization recommendations of breastfeeding their babies for at least six months.
If in 2011 their percentage was only 12.6%, in 2016 it reached 29.8%. These results confirm the growing concern of Romanians for the nutrition of children in the first year of life and for the benefits of exclusive breastfeeding in the first half of the year. The study was conducted on a representative sample, comprising 1008 participants from 23 counties, with urban-rural distribution of 52% and 48%, respectively, based on the comparison used in the 2011 study conducted by "Alfred Rusescu" Institute for Protection Mother and Child and UNICEF.
Future research should include supplementary evaluation of breastfeeding counseling and psychological counseling modalities focused on the following aspects: optimal duration of counseling, the effect of educating women family members and the impact of the use of nursing care.