Abstract

This study aimed to analyze the impact of the intention to become pregnant on breastfeeding within the first hour after delivery. This is a cross-sectional study nested in the research “Birth in Brazil: national survey into labor and birth” carried out by the Oswaldo Cruz Foundation. Multiple logistic regression was used to analyze the data of 5,563 puerperae and their newborns who participated in the study. The following women evidenced a lower propensity to begin breastfeeding in the first hour of life: puerperae who did not wish to become pregnant (OR = 0.85; CI: 0.73-0.98) and who were dissatisfied upon learning that they had become pregnant (OR = 0.72; CI: 0.61-0.83). The intentionality of pregnancy affected maternal breastfeeding behavior so that women with unintended pregnancies were less likely to initiate breastfeeding in the first hour postpartum, thus evidencing that inadequate family planning may indirectly harm breastfeeding. Therefore, the quality of family planning services should be improved to reduce unintended pregnancies and prevent unfavorable outcomes for mother-and-child health, such as the late onset of breastfeeding.

Key words
Pregnancy; Maternal behavior; Breastfeeding; Postpartum; Family planning

Introduction

Breastfeeding provides benefits for children, women, and society, and is the most sensitive, economical, and effective intervention for the promotion of maternal and child health¹1 Brasil. Ministério da Saúde (MS). Saúde da criança: nutrição infantil, aleitamento materno e alimentação complementar. Brasília: MS; 2009.^,22 Victora CG, Bahl R, Barros AJD, França GVA, Horton S, Krasevec J, Murch S, Sankar MJ, Walker N, Rollins NC, Lancet Breastfeeding Series Group. Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect. Lancet 2016; 387(10017):475-90..

Immediate postpartum has been identified as the most appropriate period for the onset of breastfeeding, due to the newborn’s better capacity to seek and suck the nipple³3 Esteves TMB, Daumas RP, Oliveira MIC, Andrade CAF, Leite IC. Fatores associados ao início tardio da amamentação em hospitais do Sistema Único de Saúde no município do Rio de Janeiro, Brasil, 2009. Cad Saúde Pública 2015; 31(11):2390-2400.^,44 Teles JM, Bonilha ALL, Gonçalves AC, Santo LCE, Mariot MDM. Amamentação no período de transição neonatal em Hospital Amigo da Criança. Rev Eletr Enfermagem 2015; 17(1):94-99. spontaneously. Breastfeeding in the first hour after delivery favors its continuity and contributes to lower neonatal mortality rates due to infections⁵5 Boccolini CS. Carvalho ML, Oliveira MIC, Pérez-Escamilla R. Breastfeeding during the first hour of life and neo-natal mortality. J Pediatr 2013; 89(2):131-136., and is an indicator of breastfeeding excellence²2 Victora CG, Bahl R, Barros AJD, França GVA, Horton S, Krasevec J, Murch S, Sankar MJ, Walker N, Rollins NC, Lancet Breastfeeding Series Group. Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect. Lancet 2016; 387(10017):475-90.^,66 World Health Organization (WHO). Indicators for assessing infant and young child feeding practices: conclusions of a consensus meeting held 6-8 November 2007 in Washington D.C., USA. Geneva: WHO; 2008.. This practice is recommended by the World Health Organization (WHO) as the Fourth Step among the Ten Steps to Successful Breastfeeding, which are part of the Baby-Friendly Hospital Initiative (BFHI)⁷7 World Health Organization (WHO). Baby-friendly Hospital Initiative: revised, updated, and expanded for integrated care. Geneva: WHO; 2009..

A significant increase in exclusive breastfeeding rates in children under six months of age has been observed in low- and middle-income countries, with an elevation from 24.9% in 1993 to 35.7% in 2013. However, while more than 80% of newborns were breastfed in almost all countries, only half started breastfeeding in the first hour after delivery²2 Victora CG, Bahl R, Barros AJD, França GVA, Horton S, Krasevec J, Murch S, Sankar MJ, Walker N, Rollins NC, Lancet Breastfeeding Series Group. Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect. Lancet 2016; 387(10017):475-90..

In Brazil, breastfeeding in the first hour of life is one of the health indicators recommended by the Ministry of Health, with population surveys showing prevalence rates of 32.9% in 1996⁸8 Brasil. Ministério da Saúde (MS). Sociedade civil bem-estar familiar no Brasil. Pesquisa Nacional de Demografia e Saúde, 1996. Rio de Janeiro: MS; 1997., 42.9% in 2006⁹9 Brasil. Ministério da Saúde (MS). Pesquisa Nacional de Demografia e Saúde da Criança e da Mulher - PNDS 2006: dimensões do processo reprodutivo e da saúde da criança. Brasília: MS; 2009., and 67.7% in 2008¹⁰10 Brasil. Ministério da Saúde (MS). II Pesquisa de Prevalência de Aleitamento Materno nas Capitais Brasileiras e Distrito Federal. Brasília: MS; 2009.. However, in a national, hospital-based study carried out from 2011 to 2012, the prevalence of this indicator in the country was only 44.5%, and the Northeast region had the lowest prevalence compared to other Brazilian regions¹¹11 Moreira MEL, Gama SGN, Pereira APE, Silva AAM, Lansky S, Pinheiro RS, Gonçalves AC, Leal MC. Práticas de atenção hospitalar ao recém-nascido saudável no Brasil. Cad Saúde Pública 2014; 30(Supl. 1):128-139., with 41.3% of newborns breastfed in the first hour of life.

Studies have shown that sociodemographic characteristics, prenatal and hospital procedures can promote or hinder breastfeeding in the first hour postpartum¹²12 Boccolini CS. Carvalho ML, Oliveira MIC, Leal MC, Carvalho MS. Fatores que interferem no tempo entre o nascimento e a primeira mamada. Cad Saúde Pública 2008; 24(11):2681-2694.

13 Boccolini CS. Carvalho ML, Oliveira MIC, Vasconcellos AGG. Fatores associados à amamentação na primeira hora de vida. Rev Saúde Pública 2011; 45(1):69-78.

14 Esteves TMB, Daumas RP, Oliveira MIC, Andrade CAF, Leite IC. Fatores associados à amamentação na primeira hora de vida: revisão sistemática. Rev Saúde Pública 2014; 48(4):697-703.

15 Sá NNB, Gubert MB, Santos W, Santos LMP. Fatores ligados aos serviços de saúde determinam o aleitamento materno na primeira hora de vida no Distrito Federal, Brasil, 2011. Rev Bras Epidemiol 2016; 19(3):509-524.^-1616 Silva CM, Pereira SCL, Passos IR, Santos LC. Fatores associados ao contato pele a pele entre mãe/filho e amamentação na sala de parto. Rev Nutrição 2016; 29(4):457-471.. It is assumed that a significant part of the circumstances and factors related to the woman’s life may also contribute to the failure to establish or discontinue breastfeeding, including the intention to become pregnant.

The intention to become pregnant is classified as intentional when the pregnancy happens at the desired time, and unintentional when women did not want the pregnancy, or when the pregnancy occurred at an unfavorable time¹⁷17 Santelli J, Rochat R, Hatfield-Timajchy K, Gilbert BC, Curtis K, Cabral R, Hirsch JS, Schieve L, Unintended Pregnancy Working Group. The measurement and meaning of unintended pregnancy. Perspect Sex Reprod Health 2003; 35(2):94-101..

Currently, the significant percentage of unintended pregnancies is an important public health issue because it is associated with behaviors harmful to health¹⁸18 Taylor JS, Cabral HJ. Are women with an unintended pregnancy less likely to breastfeed? J Fam Pract 2002; 51(5):431-436. and family planning policy failures¹⁹19 Tsui AO, Mcdonald-Mosley R, Burke AE. Family planning and the burden of unintended pregnancies. Epidemiol Rev 2010; 32(1):152-174.^,2020 McCoy SI, Buzdugan R, Ralph LJ, Mushavi A, Mahom A, Hakobyan A, Watadzaushe C, Dirawo J, Cowan FM, Padian NS. Unmet need for family planning, contraceptive failure, and unintended pregnancy among HIV-Infected and HIV-uninfected women in Zimbabwe. PLoS One 2014; 9(8):e105320.. Studies have pointed out that the intention to become pregnant influences maternal behavior during and after pregnancy, affecting breastfeeding and, thus, the health and well-being of the mother and child dyad²¹21 Dye TD, Wojtowycz MA, Aubry RH, Quade J, Kilburn H. Unintended pregnancy and breastfeeding behavior. Am J Public Health 1997; 87(10):1709-1711.

22 Kost K, Landry DJ, Darroch JE. The effects of pregnancy planning status on birth outcomes and infant care. Fam Plann Perspect 1998; 30(5):223-230.

23 Ulep VGT, Borja MP. Association between pregnancy intention and optimal breastfeeding practices in the Philippines: a cross-sectional study. BMC Pregnancy Childbirth 2012; 12:69.

24 Kost K, Lindberg L. Pregnancy intentions, maternal behaviors, and infant health: investigating relationships with new measures and propensity score analysis. Demography 2015; 52(1):83-111.^-2525 Lindberg L, Maddow-Zimet I, Kost K, Lincoln A. Pregnancy intentions and maternal and child health: an analysis of longitudinal data in Oklahoma. Matern Child Health J 2015; 19(5):1087-1096..

From this perspective, when considering the relationship between intention to become pregnant and maternal behavior regarding breastfeeding, it is necessary to start from the assumption that understanding human behavior increases the ability to predict responses and enables more effective interventions, since the attitude is related to previous intention and this, in turn, is expressed in the individual’s actions²⁶26 Ajzen I. From intentions to actions: a theory of planned behavior. In: Kuhl JE, Beckmann J, organizadores. Action Control: From cognition to behavior. Berlim: Springer-Verlag; 1985..

Therefore, understanding the impact of the intention to become pregnant on outcomes related to the mother-child binomial is essential to prevent negative repercussions of unintended pregnancies on maternal and children’s health, and contribute to an improved family planning policy. Thus, given the low prevalence of breastfeeding in the first hour of life in Brazil, and especially in the Northeast region¹¹11 Moreira MEL, Gama SGN, Pereira APE, Silva AAM, Lansky S, Pinheiro RS, Gonçalves AC, Leal MC. Práticas de atenção hospitalar ao recém-nascido saudável no Brasil. Cad Saúde Pública 2014; 30(Supl. 1):128-139., and the lack of a study on the intention to become pregnant as a predictor of this indicator in the country so far, this study aimed to analyze the impact of the intention to become pregnant on breastfeeding in the first hour postpartum.

Methods

This is a cross-sectional study nested in the research Birth in Brazil: national survey into labor and birth carried out by the Oswaldo Cruz Foundation (Fiocruz) from February 2011 to October 2012. Methods are detailed in the literature²⁷27 Leal MC, Silva AAM, Dias MAB, Gama SGN, Rattner D, Moreira ME, Theme Filha MM, Domingues RMSM, Pereira APE, Torres JA, Bittencourt SDA, D'orsi E, Cunha AJ, Leite AJM, Cavalcante RS, Lansky S, Diniz CSG, Szwarcwald CL. Birth in Brazil: national survey into labour and birth. Reprod Health 2012; 9:15..

The baseline study subjects were puerperae hospitalized for pregnancy resolution and their newborns with a gestational age of 22 weeks or more or 500g or more birth weight. Probabilistic sampling was carried out in two stages, one related to health facilities and the other to puerperae and their newborns. Health establishments were stratified by Great Geographic Region (North, Northeast, Southeast, South, and Midwest), location of the municipality (capital and inland) and type of establishment (public, private, and mixed), comprising 30 strata samples, of which at least five hospitals were selected per stratum. Thus, 1,403 of 3,961 establishments who performed 500 or more births/year were selected for the study, according to data from the 2007 Live Births Information System (SINASC). The sample of puerperae and their pairs by stratum was calculated from the cesarean rate in Brazil in 2007 (46.6%), obtaining 90 puerperae per establishment, and at least 450 puerperae per stratum. In the end, a sample of 23,940 puerperae and their newborns was distributed in 196 municipalities, 27 of which were located in the capitals and 169 in the interior²⁸28 Vasconcellos MTL, Silva PLN, Pereira APE, Schilithz AOC, Souza Junior PRB, Szwarcwald CL. Desenho da amostra Nascer no Brasil: pesquisa nacional sobre parto e nascimento. Cad Saúde Pública 2014; 30(Supl. 1):49-58..

This study comprised data referring to the Northeast Region, which included 6,096 puerperae hospitalized in 68 health establishments, of which 533 were excluded due to some condition that contraindicated or could hinder breastfeeding in the first hour postpartum, such as preterm newborns, with APGAR below 7 in the 5^th minute of life or with some malformation; and HIV-positive puerperae or puerperae who used illicit drugs, resulting in a sample of 5,563 participants.

The data were collected by previously trained health professionals and students, using electronic forms. Only three forms were used for this study: the one applied to the mothers, after the first six hours postpartum, the one completed with data contained in medical records, and another one applied to institutional administration with questions that included whether it was a Baby-Friendly Hospital (BFH)²⁷27 Leal MC, Silva AAM, Dias MAB, Gama SGN, Rattner D, Moreira ME, Theme Filha MM, Domingues RMSM, Pereira APE, Torres JA, Bittencourt SDA, D'orsi E, Cunha AJ, Leite AJM, Cavalcante RS, Lansky S, Diniz CSG, Szwarcwald CL. Birth in Brazil: national survey into labour and birth. Reprod Health 2012; 9:15..

The following variables were selected for this study from the original forms: breastfeeding in the first hour postpartum (dependent variable, generated from the recategorization of the variables breastfeeding attempt in the delivery room and time elapsed until breastfeeding attempt for the first time); sociodemographic characteristics of puerperae (maternal age, schooling, marital status and paid work); classification of the health establishment where the delivery took place (type of management and BFH certification); obstetric history (number of previous pregnancies and parity); prenatal care assistance (prenatal care, period of onset of prenatal care and number of visits); information about delivery and newborn (type of delivery, contact with the newborn in the immediate postpartum period, type of accommodation and mother-child separation time after delivery), besides variables related to the intention to become pregnant (wanted get pregnant at that time, wanted to wait longer and did not want to get pregnant), and woman’s feeling when she learned about the pregnancy (satisfied, somewhat satisfied, and dissatisfied).

The data were analyzed using the software Statistical Package for Social Science (SPSS), version 20.0. The SPSS CSAMPLE module was used for complex samples when bivariate and multivariate analyses were performed. Descriptive statistics were used in the univariate analysis, while Pearson’s chi-square test (χ²2 Victora CG, Bahl R, Barros AJD, França GVA, Horton S, Krasevec J, Murch S, Sankar MJ, Walker N, Rollins NC, Lancet Breastfeeding Series Group. Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect. Lancet 2016; 387(10017):475-90.) was used for the bivariate analysis to verify associations between the dependent and the qualitative explanatory variable, with emphasis on the intention to become pregnant²⁹29 Armitage P, Berry G, Matthews JNS. Statistical methods in medical research. London: Blackwell Scientific Publications; 2002.^,3030 Pestana MH, Gageiro JN. Análise de dados para ciência sociais: a complementaridade do SPSS. Lisboa: Edições Sílabo; 2003..

Multiple Logistic Regression (MLR) with an adjusted odds ratio (ORa) was used to explain the joint effect of independent variables on breastfeeding in the newborn’s first hour of life, while independent variables, unlike the main ones, only adjusted the model. The criterion for inclusion of variables in the logistic model was the association at the 20% (p < 0.20) level in the bivariate analysis³¹31 Hosmer DW, Lemeshow S. Applied logistic regression. New York: Wiley; 2000., and only the variables that showed an association at a 5% significance level (p < 0.05) were maintained in the model. The final MLR model was adjusted using the Enter method, which forces all variables into the model since the purpose is to explain and not predict or classify future cases³²32 Ayçaguer ICS, Ultra IMB. Regresión logística. Cuadernos de Estadística. Madri: La Muralha; 2004.^,3333 Ayçaguer WG, Ghimire DJ. Regresión logística. Cuaderno de Estadística. Madri: La Muralla; 2007..

The goodness-of-fit test (Hosmer and Lemeshow Test) showed that the final model is suitable for explaining the response variable. The multicollinearity of the explanatory variables was verified by the Variance Inflation Factor (VIF) test, adopting a VIF above four as the cutoff point for the diagnosis of multicollinearity³⁴34 Garson GD. Structural equation modeling. Asheboro-North Carolina: Statistical Publishing Associates; 2010.. However, the test did not detect dependence between the independent variables studied.

The baseline research Birth in Brazil: national survey into labor and birth was submitted and approved by the Research Ethics Committee (CEP) of the National School of Public Health of the Oswaldo Cruz Foundation. The criteria established in Resolution No 196/96 of the National Health Council³⁵35 Brasil. Ministério da Saúde (MS). Conselho Nacional de Saúde (CNS). Comissão Nacional de Ética em Pesquisa. Resolução nº 196, de 10 de outubro de 1996. Diário Oficial da União 1996; 10 out. were met, and ethical principles were assured when participants signed the Informed Consent Form (ICF). This study was carried out with the authorization of the central coordination of the baseline study.

Results

The predominant characteristics of the participants were the age group of 20-34 years (68.0%), education up to elementary school (59.2%), living with a partner (83.0%), and not having paid work (68.4%). Most deliveries occurred in public health establishments or under the Unified Health System (SUS) (86.7%), and most of the establishments were not Baby-Friendly Hospitals (BFH) (60.3%) (Table 1).

Regarding reproductive aspects, women with one or more previous pregnancies (58.2%), multiparous women (51.8%), those who reported having become pregnant at an appropriate time (44.8%), and those who declared themselves satisfied upon discovering their pregnancy (69.4%) prevailed. Almost all puerperae received prenatal care (98.5%), and most of them started in the first trimester (74.3%) and had six or more visits (71.4%). More than half of the participants had a cesarean delivery (50.3%), and the most frequent were those who reported having only seen or not having contact with their newborn in the immediate postpartum period (74.2%). Joint accommodation (63.4%) and puerperae women who declared that the mother and child had been separated for more than one hour after delivery (61.7%) prevailed. A total of 65.8% of the 5,563 puerperae participating in the study stated that they had not breastfed in the first hour postpartum (Table 1).

In the bivariate analysis, variables marital status and prenatal care met the requirement of p < 0.20 for inclusion in the multivariate model, while the intention to become pregnant and other variables showed p < 0.05. Breastfeeding in the first hour of life among women who wanted to become pregnant at the time (38.2%) and were satisfied with the pregnancy (37.3%) predominated (Table 2).

Table 3 shows the multiple logistic regression model of the variables intention to become pregnant and feeling when learning about pregnancy associated with breastfeeding in the first hour postpartum. Women who did not want to become pregnant were 15% less likely to breastfeed their children in the first hour postpartum than women who stated that they wanted to become pregnant at the time. Women who were dissatisfied when they became aware of the pregnancy were 28% less likely to breastfeed in the first hour after delivery than those who reported satisfaction at the time.

Discussion

The “fourth step to successful breastfeeding” should be carried out⁷7 World Health Organization (WHO). Baby-friendly Hospital Initiative: revised, updated, and expanded for integrated care. Geneva: WHO; 2009. considering the relevance of breastfeeding in the first hour of life for the establishment and continuation of breastfeeding, especially for maternal and child health. However, this study found a low prevalence of breastfeeding in the first hour postpartum in the Northeastern population studied, lower than the prevalence levels previously found for the region and nationally in 2006⁹9 Brasil. Ministério da Saúde (MS). Pesquisa Nacional de Demografia e Saúde da Criança e da Mulher - PNDS 2006: dimensões do processo reprodutivo e da saúde da criança. Brasília: MS; 2009. and 2008¹⁰10 Brasil. Ministério da Saúde (MS). II Pesquisa de Prevalência de Aleitamento Materno nas Capitais Brasileiras e Distrito Federal. Brasília: MS; 2009., and was classified as poor (30-49%), according to the WHO parameters for this indicator⁶6 World Health Organization (WHO). Indicators for assessing infant and young child feeding practices: conclusions of a consensus meeting held 6-8 November 2007 in Washington D.C., USA. Geneva: WHO; 2008.. This result showed the existence of barriers to the timely initiation of breastfeeding in the studied population, such as private establishment not accredited to the BFHI, being primiparous, lack of prenatal care, cesarean delivery, absence of mother-child contact in the immediate postpartum period, and unintended pregnancy.

The lower propensity for breastfeeding in the first hour postpartum among women who did not want to become pregnant, who wanted to wait longer to become pregnant, and were dissatisfied when they found out they were pregnant, revealed an association between unintended pregnancies and unfavorable results regarding early initiation of breastfeeding among northeastern puerperae, with a worse result observed among those who were dissatisfied when they learned about the pregnancy. These findings confirm the international literature, which has shown low breastfeeding rates²¹21 Dye TD, Wojtowycz MA, Aubry RH, Quade J, Kilburn H. Unintended pregnancy and breastfeeding behavior. Am J Public Health 1997; 87(10):1709-1711.

22 Kost K, Landry DJ, Darroch JE. The effects of pregnancy planning status on birth outcomes and infant care. Fam Plann Perspect 1998; 30(5):223-230.

23 Ulep VGT, Borja MP. Association between pregnancy intention and optimal breastfeeding practices in the Philippines: a cross-sectional study. BMC Pregnancy Childbirth 2012; 12:69.

24 Kost K, Lindberg L. Pregnancy intentions, maternal behaviors, and infant health: investigating relationships with new measures and propensity score analysis. Demography 2015; 52(1):83-111.^-2525 Lindberg L, Maddow-Zimet I, Kost K, Lincoln A. Pregnancy intentions and maternal and child health: an analysis of longitudinal data in Oklahoma. Matern Child Health J 2015; 19(5):1087-1096. and other unfavorable outcomes associated with unintended pregnancies, such as premature birth and low birth weight³⁶36 Shah PS, Balkhair T, Ohlsson A, Beyene J, Scott F, Frick C. Intention to become pregnant and low birth weight and preterm birth: a systematic review. Matern Child Health J 2011; 15(2):205-216..

From the viewpoint that the intention to become pregnant precedes maternal behavior regarding breastfeeding, the Planned Behavior Theory (PBT), proposed by Icken Ajzen in 1985 to explain behaviors over which individuals do not have total control, considers that attitude, subjective norm and perceived behavioral control correlate with previous intention, which in turn influences individual actions²⁶26 Ajzen I. From intentions to actions: a theory of planned behavior. In: Kuhl JE, Beckmann J, organizadores. Action Control: From cognition to behavior. Berlim: Springer-Verlag; 1985.. Thus, the maternal attitude vis-à-vis breastfeeding may show women’s desire for fertility that is met or not by family planning. Therefore, the intention to become pregnant proved to be a reliable predictor of breastfeeding in the immediate postpartum period for the population studied.

However, although the results indicate that the intention to become pregnant affected the initiation of breastfeeding in the first hour after delivery, the need to consider the context in which the pregnancy occurs so that the relationship between intention to become pregnant and outcomes for maternal and child health is analyzed has been pointed out, given the influence of socioeconomic and cultural factors on maternal behavior²⁴24 Kost K, Lindberg L. Pregnancy intentions, maternal behaviors, and infant health: investigating relationships with new measures and propensity score analysis. Demography 2015; 52(1):83-111.^,3737 Rocha AF, Gomes KR, Rodrigues MTP, Mascarenhas MDM, Freire AL. Intenção de engravidar e amamentação: revisão integrativa. Rev Bras Promoç Saúde 2018; 31:1-10.. In this sense, a study revealed a higher propensity for late initiation of breastfeeding among children from unwanted pregnancies. However, this result was observed only among children belonging to families of low socioeconomic status²³23 Ulep VGT, Borja MP. Association between pregnancy intention and optimal breastfeeding practices in the Philippines: a cross-sectional study. BMC Pregnancy Childbirth 2012; 12:69.. Nonetheless, in this study, the sociodemographic aspects were not significant after adjusting analyses, reinforcing that unintended pregnancy can affect timely breastfeeding regardless of women’s socioeconomic context.

Thus, the adverse effects of unintended pregnancies on breastfeeding in the first hour indicate the need to strengthen public policies aimed at reproductive planning, regardless of social circumstances, to reduce the impacts of unintended pregnancy on maternal and child health. Furthermore, the implementation of differentiated strategies to provide further support to women with this type of pregnancy during prenatal care, childbirth, and puerperium, is vital to attempt to reverse the expected trend of lower bonding and care concerning the baby²²22 Kost K, Landry DJ, Darroch JE. The effects of pregnancy planning status on birth outcomes and infant care. Fam Plann Perspect 1998; 30(5):223-230.^,3737 Rocha AF, Gomes KR, Rodrigues MTP, Mascarenhas MDM, Freire AL. Intenção de engravidar e amamentação: revisão integrativa. Rev Bras Promoç Saúde 2018; 31:1-10..

Nevertheless, although the intention to become pregnant has proved to be a determinant significantly associated with breastfeeding in the immediate postpartum period, it is necessary to recognize that most of the limitations for breastfeeding in the first hour of life are related to components of the hospital organization and delivery care, with little autonomy for women to decide when to start breastfeeding¹²12 Boccolini CS. Carvalho ML, Oliveira MIC, Leal MC, Carvalho MS. Fatores que interferem no tempo entre o nascimento e a primeira mamada. Cad Saúde Pública 2008; 24(11):2681-2694.

13 Boccolini CS. Carvalho ML, Oliveira MIC, Vasconcellos AGG. Fatores associados à amamentação na primeira hora de vida. Rev Saúde Pública 2011; 45(1):69-78.

14 Esteves TMB, Daumas RP, Oliveira MIC, Andrade CAF, Leite IC. Fatores associados à amamentação na primeira hora de vida: revisão sistemática. Rev Saúde Pública 2014; 48(4):697-703.^-1515 Sá NNB, Gubert MB, Santos W, Santos LMP. Fatores ligados aos serviços de saúde determinam o aleitamento materno na primeira hora de vida no Distrito Federal, Brasil, 2011. Rev Bras Epidemiol 2016; 19(3):509-524., given that a significant portion of the children was born in a child-friendly hospital. Even in this type of expressive hospital, many of them were not breastfed in the first hour.

It has been suggested that, besides the influence of relatives, friends, and partners, women’s decisions regarding breastfeeding are built according to the interaction with the community, the newborn, their daily activities, and also subjective aspects such as personality characteristics and attitude towards breastfeeding³⁸38 Faleiros FTV, Trezza EMC, Carandina L. Aleitamento Materno: fatores de influência na sua decisão e duração. Rev Nutrição 2006; 19(5):623-630.^,3939 Seehausen MPV, Oliveira MIC, Boccolini CS, Leal MC. Fatores associados ao aleitamento cruzado em duas cidades do Sudeste do Brasil. Cad Saúde Pública 2017; 33(4):e00038516.. Thus, the strengthening of prenatal care for women affected by unintended pregnancies can minimize unfavorable breastfeeding results, since it facilitates the provision of guidance on the benefits, adequate management, and the importance of early breastfeeding¹⁴14 Esteves TMB, Daumas RP, Oliveira MIC, Andrade CAF, Leite IC. Fatores associados à amamentação na primeira hora de vida: revisão sistemática. Rev Saúde Pública 2014; 48(4):697-703.^,4040 Pereira CRVR, Fonseca VM, Oliveira MIC, Souza IEO, Mello RR. Avaliação de fatores que interferem na amamentação na primeira hora de vida. Rev Bras Epidemiol 2013; 16(2):525-534.. In this sense, a study showed that educational practices during prenatal care provided faster initiation and longer breastfeeding time⁴¹41 Silva EP, Lima RT, Osório MM. Impacto de estratégias educacionais no pré-natal de baixo risco: revisão sistemática de ensaios clínicos randomizados. Cien Saúde Colet 2016; 21(9):2935-2948..

Therefore, breastfeeding is an intricate experience that requires support to achieve it and may be affected by aspects of the maternal personality, emotions, cultural influences, family relationships⁴²42 Furtado LCR, Assis TR. Diferentes fatores que influenciam na decisão e na duração do aleitamento materno: uma revisão da literatura. Rev Movimenta 2012; 5(4):303-312., and attitudes resulting from the intention to become pregnant²⁴24 Kost K, Lindberg L. Pregnancy intentions, maternal behaviors, and infant health: investigating relationships with new measures and propensity score analysis. Demography 2015; 52(1):83-111.^,3737 Rocha AF, Gomes KR, Rodrigues MTP, Mascarenhas MDM, Freire AL. Intenção de engravidar e amamentação: revisão integrativa. Rev Bras Promoç Saúde 2018; 31:1-10.. The adequacy of care in the delivery room through the postponement of routine care for healthy newborns in favor of the early approximation between mother and child⁴³43 Brasil. Ministério da Saúde (MS). Portaria nº 371, de 7 de maio de 2014. Institui diretrizes para a organização da atenção integral e humanizada ao recém-nascido no Sistema Único de Saúde. Diário Oficial da União 2014; 07 maio., is an alternative to support early breastfeeding, given the establishment of the bond, which may reduce effects of unintended pregnancies on breastfeeding. Similarly, puerperal care prevents breastfeeding discontinuity and can be an opportunity for counseling on family planning⁴⁴44 Andrade RD, Santos JS, Maia MAC, Mello DF. Fatores relacionados à saúde da mulher no puerpério e repercussões na saúde da criança. Esc Anna Nery 2015; 19:181-186..

Moreover, the relationship observed between worse breastfeeding results in the first hour of life and dissatisfaction with pregnancy strengthens the concept of PBT²⁶26 Ajzen I. From intentions to actions: a theory of planned behavior. In: Kuhl JE, Beckmann J, organizadores. Action Control: From cognition to behavior. Berlim: Springer-Verlag; 1985. that subjective aspects, such as the intention to become pregnant, influence maternal behavior concerning breastfeeding, revealing the importance of planning to reduce maternal and child health inequalities resulting from maternal behaviors resulting from unintended pregnancy.

The results reinforce the assumption that breastfeeding practices can be affected by the intention to become pregnant²¹21 Dye TD, Wojtowycz MA, Aubry RH, Quade J, Kilburn H. Unintended pregnancy and breastfeeding behavior. Am J Public Health 1997; 87(10):1709-1711.

22 Kost K, Landry DJ, Darroch JE. The effects of pregnancy planning status on birth outcomes and infant care. Fam Plann Perspect 1998; 30(5):223-230.^-2323 Ulep VGT, Borja MP. Association between pregnancy intention and optimal breastfeeding practices in the Philippines: a cross-sectional study. BMC Pregnancy Childbirth 2012; 12:69.^,2525 Lindberg L, Maddow-Zimet I, Kost K, Lincoln A. Pregnancy intentions and maternal and child health: an analysis of longitudinal data in Oklahoma. Matern Child Health J 2015; 19(5):1087-1096., which causes concern, as there is a high prevalence of unintended pregnancies among the participants, showing that the needs for reproductive planning may not be being met in the Northeastern population, which may have a multifactorial cause.

In this sense, a study showed the negligible objective and perceived knowledge regarding hormonal contraceptives of adolescents in the Northeastern capital⁴⁵45 Sousa MCR, Gomes KRO. Conhecimento objetivo e percebido sobre contraceptivos hormonais orais entre adolescentes com antecedentes gestacionais. Cad Saúde Pública 2009; 25(3):645-654., and a North American study evidenced that the correct use of contraceptives significantly reduced the risk of unintended pregnancy among the participants, with a predominance of this type of pregnancy among those who made incorrect use of some contraceptive method⁴⁶46 Sonfield A, Hasstedt K, Gold RB. Moving forward: family planning in the era of health reform. New York: Guttmacher Institute; 2014..

Thus, unintended pregnancy is a public health challenge as it contributes to maternal morbimortality due to exposure to possible risks related to pregnancy, unsafe abortion, and childbirth, also affecting ideal breastfeeding practices²⁴24 Kost K, Lindberg L. Pregnancy intentions, maternal behaviors, and infant health: investigating relationships with new measures and propensity score analysis. Demography 2015; 52(1):83-111.^,4747 Yazdkhasti M, Pourreza A, Pirak A, Abdi F. Unintended pregnancy and its adverse social and economic consequences on health system: a narrative review article. Iran J Public Health 2015; 44(1):12-21.^,4848 Yilmaz, E. Doga Ocal F, Vural Yilmaz Z, Ceyhan M, Kara OF, Küçüközkan T. Early initiation and exclusive breast-feeding: Factors influencing the attitudes of mothers who gave birth in a baby-friendly hospital. Turk J Obstet Gynecol 2017; 14(1):1-9..

We can conclude that the intention to become pregnant affected breastfeeding in the first hour postpartum among puerperae in the Northeast of Brazil since unintended pregnancies reduced the likelihood of timely initiation of breastfeeding. Therefore, family planning shortcomings can result in unintended pregnancies, and these may affect maternal behavior regarding breastfeeding, which can result in lower maternal and child health indicators and contribute to the perpetuation of preventable problems with adequate breastfeeding practices.

This study had a limitation typical of cross-sectional studies, which restricts the determination of causal relationships between variables and the outcome. On the other hand, its strengths are weighted sampling, representative for the entire region studied, and the findings regarding the association between intention to become pregnant and maternal behavior regarding breastfeeding in the first hour postpartum, unprecedented in Latin American literature.

The study shows the need for investments in public policies aimed at reproductive planning to prevent unintended pregnancies and their impact on maternal and child health. Furthermore, the results may contribute to the proposal of longitudinal studies that precede pregnancy and investigate women and their children regarding the issue of breastfeeding up to six months after delivery, to clarify better the causal relationship and possible outcomes in the medium term.

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