Prevalence of educational practices about exclusive breastfeeding (EBF) in Cuiabá-MT

Objective: To describe the prevalence of educational practices in health on exclusive breastfeeding (EBF) in the city of Cuiabá between July and December 2012. Methods: This was a descriptive, cross-sectional study, carried out among hospitalized women. The sample consisted of 306 women in the immediate postpartum period. Data were collected through a semi-structured questionnaire. Results: Eight years of schooling or more (OR = 1.77); income of up to two minimum wages (OR = 1.22); planned pregnancy (OR = 1.31); start of antenatal care in the first term (OR = 1.65) and primiparous (OR = 1.21) were features that appear associated with a greater chance of receiving breastfeeding training than other women. Conclusion: It is necessary to rethink these practices, in order to carry out educational activities that aim for changes in the professional/user relationship, with a view to the welcoming of pregnant women.


INTRODUCTION
Breast milk is currently considered the ideal food for infants, especially in the first six months of life, with benefits superior to other milks.The justification is based on the fact that it is rich in fats, minerals, vitamins, enzymes and immunoglobulins.Moreover, it has nutritional advantages, which promote growth and development and influence the future academic performance of children 1 .
Breastfeeding prevents gastrointestinal, respiratory and urinary tract infections; besides having a protective effect on allergies.Breast milk makes babies adapt better to other foods.In the long term, we can also refer to the importance of breastfeeding in the prevention of diabetes and lymphomas.With regard to the benefits for the mother, breastfeeding facilitates an early uterine involution due to the release of oxytocin, and is associated with a lower likelihood of her developing cancer of the breast and ovaries, as well as the recovery of her pre-gestational weight.It mainly allows the mother to feel the unique pleasure of breastfeeding.Apart from all these benefits, breast milk is the cheapest and safest method of feeding infants and, in most situations, protects mothers from a new pregnancy 2 .
The World Health Organization and the Brazilian Ministry of Health recommend exclusive breastfeeding (EBF) until the sixth month of the child's life, defining it as follows: "only receive milk from their mother or human milk banks, and no other liquids or solids except for vitamins, minerals and medicines".After the age of six months, the inclusion of complementary foods is recommended up to two years of age, along with breastfeeding 3:2,4 .
Despite an upward trend in breastfeeding practices in the last three decades, it is still not possible to see mothers breastfeed their children exclusively until the sixth month of the child's life 5 .In Brazil, in general, breastfeeding is growing every year, but still far from what is widely recommended 6 .
According to the 2 nd Survey of the Prevalence of Breastfeeding in the state capitals and the Federal District, held in 2008, the prevalence of exclusive breastfeeding in the first six months of life is 41%.In the same research, the capital of Cuiabá deserves special mention, where only 27.1% of mothers maintained EBF for six months.When compared with other state capitals, Cuiabá ranks first in early weaning 7 .
These data point to the relevance and rationale of the present study, whose problem was implied in the understanding that a woman's decision to breastfeed may be the result of an educational activity, considering that education is a powerful instrument for the emancipation of the decision and subject.
Educational practices are health education activities, designed to develop both individual and collective capacity, in order to improve the quality of life and health, ensuring access to quality health services.Health education can be seen as a constant process of intervention for the individual and the community to have the means to maintain or restore their state of health, which are related the organic, psychological, socioeconomic and spiritual factors 8 .
Health education should be present at all care levels, but it is believed that it is in primary care that it is more meaningful to the subjects, because it can be the base to promote preventive actions and train individuals to be aware of their citizenship, to develop decision-making power over their own health and responsibility for the health of the community they live in.But for that to happen effectively, the sharing of knowledge, wisdom and experiences is needed 9 .
It is considered to be critical to conduct educational activities during all stages of pregnancy and childbirth, but it is in the prenatal stage that women should build for themselves the reasons that help in decision making to experience childbirth in a positive way, have less risk of complications in the puerperium and succeed in breastfeeding 10 .
Thus, the present article aimed to describe the prevalence of educational practices in health on exclusive breastfeeding in the city of Cuiabá between July and December 2012.This study permits diagnosing the failures in the lack of educational practices in health in the town under study.This is an initial way to rethink strategies and methods to reach these women.

METHOD
This descriptive, cross-sectional, quantitative study was undertaken at the Charity Hospital St. Helena (CHSH) in the city of Cuiabá.This service was chosen because it is a Baby-Friendly Hospital (BFH) and receives about 70% of all births in the capital of Mato Grosso, accepting pregnant women from all regions of the city.
According to population estimates for 2011, Cuiabá had a female population of childbearing age (10-49 years) corresponding to 192,422 residents.In the same year, 9,956 births occurred, among them 6,955 at the hospital observed in this study.The study was conducted using a sample calculated from of population and reported birth data with a 95% confidence interval (= 2 standard deviations) and sampling error of 2%.

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Proportion to be estimated: p = 0.5 (no information about the proportion of the population).
Equation used for the sample size (with correction for finite population): n = (σ^2.p.q.N)/(e^2 (N-1)+σ^2.p.q) Prevalence of educational practices about exclusive breastfeeding Barbosa LN, Santos NC, Moraes MAM, Rizzardi SD, Corrêa EC N is the population size of the study and p is the prevalence of the trait in the population of interest.
This formula calculates the sample size for finite populations of size N, and uses the information about the prevalence rate, sampling error and desired confidence interval.
This results in an initial sample of 1839 women of childbearing age.Assuming that there is a relative homogeneity of births between the months of the year, the final sample size was obtained by dividing the total sample by 12 months.The projection is a sample of 153 women per month.We chose to perform the collection in two months (December 2012 and January 2013) and thus expand the database and the sample population.
Data were collected from women in the postpartum period, and the selection of women was defined by the following inclusion criteria: mothers who had given birth in the last 24 hours and who had the ability to breastfeed.Exclusion criteria: mothers who by known biological factors were prevented from experiencing breastfeeding (i.e. with a diagnosis of active tuberculosis, leprosy, people with HIV, herpes, simplex virus in the breast, severe debilitating diseases, maternal malnutrition and need to ingest medicines harmful to the child over a long period).
Data were collected through a semi-structured questionnaire consisting of three groups of variables that included related issues: the identification data of the woman; data on prenatal care and data on educational practices in health about EBF.
Data were organized and analyzed using measures of frequency and distribution and the prevalence ratio was calculated using Epi Info software version 6.0.
The study results are consistent with information about antenatal health care services provided to pregnant women in the second half of 2012.This projection is based on the fact that 70% of women sought antenatal care before the fourth month of pregnancy.
For this study, the recommended ethical and legal aspects were observed and regulated by of the National Health Council (NHC) Resolution 196/96, in force at the time of the study.Approval was obtained from the Research Ethics Committee of the University Hospital Júlio Muller under number 146 386.After being informed about the objectives, the method and the potential benefits of the study, each study participant signed the Instrument of Consent.The study also received approval from the director of the institution where the research was conducted.

RESULTS
The sample population was composed of 306 postpartum women who completed the questionnaire and were still admitted at the study hospital.
The study participants' average age was 27.1 years.This finding reveals an appropriate age for the conception of a baby, since the Ministry of Health (MOH) recommends that the best age to conceive a child is more than 15 years and less than 35 years.However, we know that teen pregnancy has increased in recent years, revealing the troubling demands to attend to these clients.In our findings, the average age of the participants reveals a situation contrary to what the MOH has indicated as frequent among women who become pregnant 11 .
The education level of the participants was mostly concentrated (55.3%) in the group that completed high school and completed or are taking higher education.However, the data correspond to a lower level than that found in the city's female population though.In 2010, 70.61% of the female population in Cuiabá aged 15 years or more held a secondary education degree or higher.
With regard to skin color, approximately 65% of the women self-reported that they were mulatto; 16.4% considered themselves white and 16.4% black.The amount of natives and yellows amounted to less than 3% of the total.
Of the total participants, (n = 100) reported having a remunerated job, 72% of whom affirm a formal employment contract.
According to Table 1, approximately 75% of the women reported having unplanned pregnancies.However, this factor did not discourage them from seeking pregnancy monitoring, as 99.7% of the total received antenatal care.
Of all the women who answered the questionnaire, 48.9% reported having received some professional guidelines for monitoring during the antenatal period, whereas only 20.3% of women reported having participated in some of the educational practice conversation groups and lectures.It should be emphasized that providing orientations on exclusive breastfeeding corresponds to what the Ministry of Health recommends as the minimum a routine antenatal consultation should contain 11 .
Another fact related to access to health services refers to the sector where the woman received the antenatal care.We identified a large concentration in mixed services, involving the search for care in public and private units.This information shows the deficiencies in the health service network, especially in the provision of specialized tests.Of the study participants, 54.1% received antenatal care in the public sector, but resorted to ultrasound tests in private health services.
Women are increasingly seeking antenatal care early.The search for the service occurred mostly (73.4%) in the first term of pregnancy.The average number of antenatal consultations was about nine throughout the gestational period, higher than the minimum number of visits recommended by the Ministry of Health.

Prevalence of educational practices about exclusive breastfeeding
Barbosa LN, Santos NC, Moraes MAM, Rizzardi SD, Corrêa EC We emphasize the following data on the prevalence and prevalence ratio (PR) indicating an association between the practice of health education and some variables that were most significant in the study.Table 2 shows the variables with a prevalence ratio superior to one.The variables that were highlighted were: eight or more years of study; income up to two minimum wages; planned pregnancies; start of antenatal care in the first term, and first pregnancy.
Women with eight or more years of study reported having participated in or having received guidance on breastfeeding, 1.77 times more than those with less than eight years of study.

Prevalence of educational practices about exclusive breastfeeding
Barbosa LN, Santos NC, Moraes MAM, Rizzardi SD, Corrêa EC Have income up to two minimum wages was seemingly a feature that distinguished the pregnant women as targets of health education activities (PR = 1.22).
Women who planned their pregnancy had more guidance on breastfeeding (OR = 1.31) than those who did not.
The start of antenatal care in the first term also appears as a factor that distinguishes women who received more guidance on breastfeeding (PR = 1.65).
The primipara women were 1.21 times more likely to receive information than other women.

DISCUSSION
The average age of participants is relatively high compared with other studies conducted in Brazil.The younger maternal age may be related to the shorter duration of breastfeeding, perhaps motivated by some difficulties, such as: low educational level, lower purchasing power and, often, the fact that they are single 12 .
We can consider that living with a companion can be seen as fundamental for greater adherence to breastfeeding because it promotes better understanding of the benefits, and the presence of a companion may be beneficial, especially if he encourages, supports and helps in general tasks, both house chores and in child care 13 .
The increase in female participation in the labor market in the country has been one of the social changes since the 70's.Statistics point to an increasingly high presence of women in the Brazilian labor market and shows no inverse trend.This inclusion implies a change in the behavior of women regarding breastfeeding.However, our findings did not suggest a negative influence of work on EBF, because the mothers reported working outside the home as uncommon problems regarding interference in the maintenance of breastfeeding 12 .
Even before this "almost perfect" coverage related to antenatal care, the prevalence of exclusive breastfeeding in the first six months of life remains low in the capital of Mato Grosso 7 .
Health education activities, mainly conducted in groups, are resources that permit further approximation between health professionals and the population, contributing to the supply of humanized and skilled care, as they are based on dynamic and reflexive human interactions.The group work technique promotes the strengthening of the individual and group potential, the value of health, the use of available resources and the exercise of citizenship as important tools in the development of educational practices in health 14 .
Nevertheless, there are still difficulties the health professionals need to overcome.Welcoming seems to be a practice some professionals still do not practice.In addition, some nurses' lack of theoretical and practical knowledge in antenatal care and the lack of dialogue between medical professionals and the multiprofessional team impairs holistic care for pregnant women 15 .
Comprehensive care can be achieved through a focus on local needs and with the interdisciplinary and intersectional resources available.Through the articulation of these factors, popular education, social control, and the promotion of humanized health care are achieved.Educational actions in the care process can be developed in a context which many professionals are inserted in, the interdisciplinary articulation that provides the best quality of health care.In the processes of health education, the need for distinguished and welcoming care is apparent, granting the professionals a more comprehensive tool for care 16 .
In Brazil, access to quality care, ensuring access, admission and humanization, is still the privilege of a few women, which implies an increase in problems related to reproductive health, such as the risk of maternal death from pregnancy, childbirth or puerperium 17 .

Prevalence of educational practices about exclusive breastfeeding
Barbosa LN, Santos NC, Moraes MAM, Rizzardi SD, Corrêa EC Health professionals' approaches to breastfeeding during antenatal care are crucial to guarantee the exercise of women's right to breastfeed their children, permitting reflection on this practice, knowledge of their rights and preparation for its management.Similarly, care given to women and children in the puerperium should be able to intervene early, welcoming and listening to the difficulties to start this practice, expectations and desires, not only in relation to breastfeeding, but other aspects of their lives, ensuring that comprehensive care is a basic assumption of health care programs for women and children 18 .
It is known that educational activities during the antenatal period may be lacking, as women who go through a pregnancy without complications and attend antenatal care still reach the last month showing a lack of knowledge about alterations caused by pregnancy and unprepared to experience childbirth.These results reinforce the concern with regard to the way that antenatal education is being carried out 10 .
Let us assume that mothers with less education in years would demand more from health professionals in terms of their doubts and questions on the subject as, in this study the mothers' high level of education was appointed as a positive influence on the duration of EBF.
Maternal education constitutes a factor that affects the motivation to breastfeed.In many developed countries, mothers with higher levels of education tend to breastfeed longer, mainly due to the possibility of greater access to information about the benefits of breastfeeding.In developing countries, underprivileged mothers, often unmarried and uneducated, begin antenatal care later and, consequently, the decision on how to feed the baby also occurs later 12 .
The distinction between women who planned the pregnancy and those who did not is perhaps related to greater emotional involvement with pregnancy and the desire to become a mother, which could be an extra motivation for asking health professionals on the subject.
In our study, we found the possibility that the chances of pregnant women being reached by the health education activities increase the extent to which these women join antenatal care services early.
The wider range of guidelines available to first-time mothers may be related to the health professionals' understanding that multiparous woman have had greater opportunity to access information and experiences from a previous pregnancy than mothers with their first child.Thus, first-time mothers are preferably chosen for health-education activities.
Given the above, nurses need to realize the importance of antenatal health education to effectively and continuously develop a critical awareness in pregnant women, thus causing the pregnant woman to reflect on their attitudes and gain empowerment in relation to EBF until six months and continuing until two years, through processes that lead to emancipation, since knowledge enables women to know themselves and decide.
Freire argues that, for the teaching/learning process, the relationship between educator and student should be aggregative, conceiving that one learns from the other, through dialogue and reflections to solve everyday problems.The educator shall comply with the limitations and prior knowledge of the student and share the experiences of their reality 19 .
Thus, it is relevant to value the educational strategies with this goals, in view of the singularity of pregnant women's experience ands its implications for successful breastfeeding.When considering health education, the subjects involved should be empowered.They should occupy a central position in the process, whose purpose is to promote their emancipation as a way to give significance to the themes addressed.Therefore, in educational practices, women should be considered as active subjects of this process, and not as tabula rasa or a deposit of contents of traditional education that reproduces ready and finished concepts 19 .
The present study is limited by the factor of seasonality, since data were collected only from the second half of the chosen year.Perhaps, if the data were collected over a full year, we would get different results that would permit generalizations about the population under study.Another factor in our study is the limit related to the location chosen, since we chose the reference hospital for births in the capital Cuiaba -MT (70% of total births), although there are other hospitals that perform less deliveries.Perhaps the inclusion of these other units would allow us to accomplish more reliable generalizations on the capital studied.

FINAL CONSIDERATIONS
Despite the 99.7% coverage rate of antenatal care and 73.4% of pregnant women starting in the first term, we note that 48.9% of postpartum women received guidelines on exclusive breastfeeding during the antenatal period.In total, 62 women (20.3%) participated in lectures/conversation groups.In relation to the professionals who addressed the EBF topic, doctors stood out with 38.2% of the total.
This reveals a major deficiency in the quality of care provided to pregnant women during antenatal monitoring, since the guidelines about pregnancy and, if so, on EBF, make up the minimum required from professionals in this stage of the pregnant woman's life in order to support their decision process.
Regarding the data on the prevalence and prevalence ratio about the association between health education and some significant variables, the following stood out: having eight or more years of study; income up to two minimum wages; planned pregnancies; start of antenatal care in the first term and first pregnancy.

Prevalence of educational practices about exclusive breastfeeding
Barbosa LN, Santos NC, Moraes MAM, Rizzardi SD, Corrêa EC These data demonstrate that there may be a gap in the care given to pregnant women because the prevalence of early weaning found in Cuiabá remains high, despite knowing that information about the benefits of exclusive breastfeeding for mother and infant are increasingly disseminated.
It is noticed that, in the prenatal period, health professionals are responsible for raising the pregnant women's awareness about the benefits of exclusive breastfeeding, as this period begins the welcoming.Such practices are guided through communication, listening, trying to understand the reality of this woman, her socioeconomic, cultural, family context.Accordingly, one should strengthen this professional-patient relationship to establish trust, so as to provide orientations on problem-free breastfeeding, showing the benefits of breastfeeding, developing the pregnant women's critical awareness on the importance of EBF.
In this context, health education can be an indispensable tool because it allows one to develop activities directed at the principles of educating, thereby facilitating the mothers' awareness on these values.For this to happen, the women need to know their own body, because this enables them to develop their autonomy and empowerment.
Without empowerment, the users are unable to make decisions favorable to their health, because they are unaware of their rights and do not have sufficient knowledge to identify the type of care received and to judge what would be most appropriate.
It is necessary to change these practices in order to rethink and reframe educational activities that seek to make changes in the professional/user relationship, aiming at the admission of pregnant women in the context of breastfeeding promotion, protection and support.

Table 1 .
Characterization of educational practices in healthcare about breastfeeding in Cuiabá -MT in the year 2012 This alternative does not total 149 nursing mothers (those who received orientations) as more than one alternative could be marked on the questionnaire. *

Table 2 .
Prevalence and Prevalence Ratio of childrearing practices on breastfeeding in relation to some variables of the study in Cuiabá -MT in the year 2012