Pre-natal and puerperium factors that interfere on self-efficacy in breastfeeding Los factores del prenatal y del posparto que interfieren en la autoeficacia de la lactancia materna

Objective: To analyze which factors related to pre-natal and puerperium that interfere on self-efficacy in breastfeeding to hospitalized women in puerperium in joint accommodation. Methods: Quantitative research, transversal, developed with 322 women in puerperium, in the period of December 2011 to March 2012, with an instrument composed by Breastfeeding Self-Efficacy Scale-Short Form and a characterization form of the women in puerperium. The bi-varied analysis was performed in the Statistical Package for Social Science software. Results: Most of women in puerperium showed high self-efficacy on breastfeeding. It was occurred statistically significant association of self-efficacy on breastfeeding with the fact that the baby had been placed to suck after the first hour. Conclusion: The promotion of self-efficacy in maternal breastfeeding should begin in the pre-natal, being early stimulated on the maternity and accompanied during puerperium and childcare.


INTRODUCTION
Breastfeeding (BF) is the best way to nourish a baby, as it provides quality of life and protection to the health of the child and the mother, in addition to create stronger links between both of them.However, breastfeeding is not a natural organic and spontaneous act, demands continuous learning and understanding of the family and the health care team 1 .
Thus, it is necessary to ensure adequate prenatal care, in order to prevent, diagnose and treat the undesirable events in pregnancy, aiming at the well-being of the pregnant woman and her fetus, in addition to direct about childbirth and the puerperium.In puerperal period the nursing staff has an important educational role to the care that the woman in puerperium must have with herself and with the baby 2 .
Due to the short period in which the woman in puerperium remains hospitalized in the joint accommodation (JA), postpartum care is built essentially within the family, which can transmit beliefs, taboos, habits, attitudes, and behaviors 2 .In addition, there are other factors involved in the difficulty of breast-feeding or in early interruption of breastfeeding, among them the ignorance of mothers about BF, in addition to the social, political and cultural aspects which affect breastfeeding 3 .
In this sense, one of the aspects that can positively influence the choice of maternal breastfeeding is the self-efficacy in breastfeeding, which is characterized by confidence or expectation of women with respect to their knowledge and skills to breastfeed their baby successfully.So, the more elevated the self-efficacy the greater can be the period of BF.During the prenatal period, 27% of women with low levels of confidence in breastfeeding discontinued BF in the first week after childbirth.Women with low level of confidence in the BF, had 3.1 times more risk to stop breastfeeding than those who had complete confidence 4 .
According to the perception of women in puerperium regarding to the self-efficacy in breast-feeding, it seeks to build evidence in relation to women's attitudes about breastfeeding that culminate with the development of strategies for the promotion of BF and increased its prevalence.So, to identify the factors related to prenatal and puerperium, that interfere with the maternal self-efficacy will entail in the practice of breastfeeding, because it will be possible to support interventions that stimulate the beginning and maintenance of BF, through a focus on maternal and child health of individualized manner according to the characteristic of the women in puerperium.
Therefore, the objective of this study is to analyze the factors related to prenatal and the puerperium that interfere in self-efficacy in breastfeeding to the women in puerperium hospitalized in joint accommodation.

Review of the literature
As a search performed in LILACS and PubMed databases in order to identify the factors that interfere in self-efficacy in breast-feeding, it was possible to evidence that self-efficacy is a concept which refers to personal skill to perform, with success, certain activities or behaviors that produces a desirable result 5 .
It can also be defined as the personal conviction that can be performed an action to produce desirable results in a given situation 6 .
In his studies, Bandura noticed that self-efficacy interfere with health behaviors, because people need to believe that they can adhere to healthy behaviors, so they can undertake the necessary efforts to reach them.Furthermore, he claims that one of the processes that can interfere with the behavior of people is their motivation 5 .
Thus, the expectation of self-efficacy (to be judged to be able to accomplish something) is based on four information sources 5 that underlie the expectation of self-efficacy and which can be found in the everyday life of the JA, namely: personal experiences, if the woman already has breastfed previously and was successful, she will be more secure as to their performance and, on the contrary, if the experience was negative, this can make her insecure, fearful and, consequently, less confident in their ability to breastfeed the child; observation of experiments or vicarious experience, because in the JA women can exchange experiences, observe the performance of the other, to talk, to take questions, and encourage each other, making them more confident and safe; verbal persuasion that occurs through experienced people, professionals and consultants who can convince the person of their potential and ability to assume a behavior; and emotional responses, because those answers with physical effects such as anxiety, fear, fatigue and pain, influence negatively on perception of self-efficacy 7 .
These elements may influence the choice, in the realization and maintenance of breastfeeding.With it, it is established a behavior that will be initiated and maintained in accordance with the interpretation of each individual.

METHOD
It is a quantitative research and with transversal delineation, developed in the Tocogynecology Unit of the University Hospital of Santa Maria (UHSM), located in the Central-West region of the State of Rio Grande do Sul (RS)/Brazil.The sample for convenience of 322 women in puerperium was calculated from a statistical formula with 95% confidence interval and sampling error of 0.05; based on the number of childbirths made at the institution in the year 2011 (1,938 Childbirths).
The women in puerperium were selected from the promptbook, according to the demand of hospitalization in the unit, considering as criteria for inclusion in the study women in the immediate postpartum period and after the six-hour period of childbirth; from 12 years old 8 ; women in puerperium hospitalized in JA accompanied of the newborn (NB) with good vitality, effective suction capacity and thermal control.
The exclusion criteria were women who presented clinical complications at the time of data collection; obstetric complications in puerperal period; women in puerperium with some cognitive and mental limitation; maternal infectious condition that made impossible or contraindicate the BF; and women in puerperium hospitalized in JA with children hospitalized in the Neonatal Intensive Care Unit.

Prenatal and puerperium factors self-efficacy in breastfeeding
Rodrigues AP, Padoin SMM, Guido LA, Lopes LFD Data collection began in December 2011 and was completed in March 2012.The data were collected directly with the women in puerperium, in their own bed or in a reserved room, according to preference.
For its accomplishment, a form was used to characterize the obstetrical factors related to pregnancy and current puerperium, in addition to the Breastfeeding Self-Efficacy Scale -Short Form (BSES-SF), which is composed of 14 items.To identify the self-efficacy was used the sum of the scores obtained on each item in the range: low effectiveness (14 to 32 points); average effectiveness (33 to 51 points) and high efficiency (52 to 70 points) 9 .
For database composition, dual independent typing was performed, with a view to ensure the accuracy of the data, in the Epi Info software version 3.5.The analysis of the variables was carried out in Statistical Package for Social Science software (SPSS version 17.0), through absolute frequencies, relatives and statistical significance test (p < 0.05).
In addition, the internal consistency of BSES-SF was evaluated using internal consistency coefficient of Cronbach's Alpha, with value obtained of 0.89, which confirms the suitability of the instrument to the chosen population and which can be comparable to the original version of 0.94 10 .In addition, it was higher than the values obtained in the study of Turkey (0.87) 11 and in a study in the northeastern region of Brazil (0.74) 12 .
issues were guaranteed through the standards of Resolution Nº 196/96 of the National Health Council of the Health Ministry, using the Free and Clarified Consent Form and, in the case of women in puerperium are teenagers, the Free and Clarified Assent Form.The project was approved by the Research Ethics Committee of the Federal University of Santa Maria in November 2011 (CAAE: 0323.0.243.000-11).

RESULTS
With respect to the age of women in puerperium, the average was 26 years old, and 36% had incomplete elementary school and average monthly income of 1.9 minimum wages.Part of them were single (66%) and 67% were not working.
There was a predominance of concordance of the women in puerperium with relation to the statements of BSES-SF.Thus, of 322 women in puerperium, 261 (81%) had high self-efficacy, while 61 (19%) had average self-efficacy.
According to the data presented in Table 1, it is observed the relationship between self-efficacy on breastfeeding with the variables of pregnancy and current puerperium.It was found that there was statistically significant association between putting the baby to suck after the first hour of birth (p = 0.018) with self-efficacy in breastfeeding (Table 1).

DISCUSSION
The women in puerperium in the study had high and average self-efficacy in breast-feeding, which can indicate that high self-efficacy scores in hospital discharge can reflect on exclusive breastfeeding of the child.Thus, the BSES-SF can be a tool for identifying the need for intervention 13 .
It was contacted in this study that the number of pre-natal consultations did not influence significantly the self-efficacy of breastfeeding.This fact can be considered with another study also descriptive and quantitative approach that aimed to verify the perception of 155 women in puerperium regarding the self-efficacy in breast-feeding and that also characterized the obstetrical profile of them, held near a maternity school in the city of Fortaleza (Ceará), which indicated that despite not having found association it shows that women who carry out less than five prenatal consultations breastfeed for less time than they do between five and nine appointments 9 .
The realization of prenatal also promotes the self-efficacy in breastfeeding, because this escort is the benefit the preparation of the mother and family to the BF.In this way, the prenatal contributes to the success of breastfeeding, and women should be informed of the benefits of this practice, of the disadvantages of using other milks and breastfeeding techniques, to increase the ability and confidence of the mother 14 .
The woman prepared during the prenatal period, through information and guidance pertaining to pregnancy, childbirth and the puerperium, will face these periods with greater security, harmony and pleasure, because the lack of information could generate unnecessary concerns and frustrated expectations.It is considered that prenatal is a propitious moment for the couple to receive the necessary guidelines, once this period is motivated and receptive to such information, so this time should be useful for the health professionals 2 .
Also it was not found significant statistical association between self-efficacy in breastfeeding and receiving guidelines of BF in prenatal.In descriptive study conducted with 50 women in puerperium of a maternity hospital in the city of Rio de Janeiro, which aimed to meet the vision of women in puerperium in relation to the care provided by healthcare professionals regarding the practice of breastfeeding, it was identified that more than half of the women were not oriented or felt lack of guidance provided by a professional during the prenatal period 15 .
The access to information, especially the guidelines of health professionals, has influence on confidence of the mother in breast-feeding.The information must get to troubleshooting, as well as to prevent and help the mother to overcome the difficulties that the process of breastfeeding can cause, leaving the mother more confident 14 .
In this study, the type of childbirth related to self-efficacy in breastfeeding showed no statistically significant association.This variable also did not influence significantly the self-efficacy in a study in Portugal, but the authors claim that the type of childbirth constitutes as a good indicator of influence on breastfeeding 16 .
It was also not found significant difference in the score of BSES-SF between mothers who have given birth by vaginally compared to those who underwent cesarean delivery in the United Kingdom 13 .By contrast, in a study conducted in Canada  with 491 nursing mothers that aimed to reduce the number of items in the BSES, considering its reduced form (BSES-Short Form); and in the study of Turkey developed with 144 pregnant women and 150 women in puerperium to translate the BSES-SF for Turkish language and to evaluate the psychometric properties of the scale among women in the prenatal and postnatal periods; significant differences were found in the score of BSES-SF among mothers who underwent vaginal birth and those who have made caesarean 10,11 , indicating an increase in self-efficacy in breastfeeding.
The childbirth is considered, in most cases, as a significant event and remarkable in family life.Thus, the realization of vaginal birth and its positive experience establish feelings of pleasure and perceived effectiveness, indicating better capacity to deal with and manage the difficulties with breastfeeding 14 .
The statistically significant relationship between putting the baby to suck after the first hour of postpartum with the breastfeeding self-efficacy goes against another study that validated the BSES-SF, to the Portuguese reality using a sample of 31 women in puerperium and it was identified that women who breastfed immediately after childbirth had significantly higher values on the scale of self-efficacy in breastfeeding as compared to women who did not 16 .
Breastfeeding in the first hour of life is recommended by the World Health Organization (WHO) and promoted through the fourth step of the Baby Friendly Hospital Initiative (BFHI), which indicates the contact of NBs with their mothers in the first few minutes of life and thus facilitates breastfeeding during this period.This contact is important for women empowerment and establishment of the bond between mother and child in addition to increasing the duration of BF, the prevalence of BF in hospitals and reduces neonatal mortality 17 .
In addition, the lack of contact with the NB soon after birth can reduce the prevalence of BF in the first hour.This contact is often delayed or minimized in favor of the various routines, care and certain practices by the health team and by the institutions.

Table 1 .
Distribution of obstetric variables according to medium and high self-efficacy in breastfeeding.Santa Maria, Rio Grande do Sul, Brazil/Brazil, 2013 * Chi-square test.