Abstract

This article aims to understand the implications of the COVID-19 pandemic on breastfeeding and health promotion actions within primary care from the perception of breastfeeding women. This qualitative study was developed with 24 women who breastfed during the first year of the pandemic. Data were analyzed using Content Analysis and interpreted in the light of the Interactive Breastfeeding Theory (IBT). The pandemic affected the vulnerability of the mental health of breastfeeding women, entailed difficulties for the continuity of breastfeeding and early insertion of formulas, impacted COVID-19 preventive measures in breastfeeding, and produced changes in the work of breastfeeding women. Furthermore, areas for improvement were identified in health promotion actions and the mother-child binomial support due to the interruption of childcare visits. Actions to promote child health in primary care were unsatisfactory. However, most study participants maintained exclusive breastfeeding for the first six months, which could adversely affect child morbimortality.

Key words:
Breastfeeding; Health Promotion; Primary Care; Women; COVID-19 pandemic

Introduction

According to the Ottawa Charter¹1 Primeira Conferência Internacional sobre Promoção da Saúde. Carta de Otawa. In: Brasil. Ministério da Saúde (MS), organizador. As cartas da promoção da saúde. Brasília: MS; 2002. p.19-28., Health Promotion (HP) empowers the community to improve the quality of life and health, encouraging active participation in controlling this process.

In Brazil, it is possible to develop skills and empower people and communities to act actively toward improving the quality of life²2 Sousa MLT, Lima FA, Sousa RM, Paresque MAC, Carvalho WRL. Por uma nova promoção da saúde com arranjos participativos emancipatórios na estratégia saúde da família. In: Catrib AMF, Dias JA, Frota MA, organizadoras. Promoção da Saúde no Contexto da Estratégia Saúde da Família. Campinas: Saberes Editora; 2011.. To this end, the health team must be based on interdisciplinary practice, valuing local potential and intersectoral partnerships to provide comprehensive care and strengthen social participation²2 Sousa MLT, Lima FA, Sousa RM, Paresque MAC, Carvalho WRL. Por uma nova promoção da saúde com arranjos participativos emancipatórios na estratégia saúde da família. In: Catrib AMF, Dias JA, Frota MA, organizadoras. Promoção da Saúde no Contexto da Estratégia Saúde da Família. Campinas: Saberes Editora; 2011..

In the last three years, HP practices within Primary Health Care (PHC), especially those focused on women’s health, were impaired due to the COVID-19 pandemic, which changed the provision of care to this population, causing difficulties and problems regarding healthcare³3 Becker NV, Michelle H, Moniz MD, Tipirneni R, Dalton VK, Ayanian JZ. Utilization of women's preventive health services during the COVID-19 pandemic. JAMA Health Forum 2021; 2(7):e211408..

The need for social distancing imposed by the COVID-19 pandemic also hampered access to reproductive health programs, with interruptions and changes in the care model in prenatal, childbirth, and postpartum care services⁴4 Sahin BM, Kabakci EN. The experiences of pregnant women during the COVID-19 pandemic in Turkey: A qualitative study. Women Birth 2021; 34(2):162-169.. Moreover, women struggle to contact their primary (family, friends) and secondary support (professionals, health, and social assistance services), besides addressing an overload of news and information regarding the growing number of confirmed cases and deaths caused by the coronavirus⁵5 Paixão GPN, Campos LM, Carneiro JB, Fraga CDS. A solidão materna diante das novas orientações em tempos de SARS-COV-2: um recorte brasileiro. Rev Gaucha Enferm 2021; 42:1-13..

Given this setting, a practice that may also have been affected by the pandemic was breastfeeding (BF). Scientific evidence shows that the lack of professional support for breastfeeding women due to the pandemic interrupted breastfeeding globally⁶6 Milani GP, Porro A, Agostoni C, Gianni ML. Breastfeeding during a Pandemic. An Nutr Metabol 2022; 78(1):17-25.. Data from a study in the United Kingdom⁷7 Brown A, Shenker N. Experiences of breastfeeding during COVID-19: Lessons for future practical and emotional support. Maternal Child Nutr 2021; 17(1):e13088. showed that the most frequent reasons for interrupting BF in the pandemic are the lack of face-to-face professional support and women deciding to stop breastfeeding due to its insecurity, with a risk of transmitting the virus to their babies.

According to the Ministry of Health⁸8 Brasil. Ministério da Saúde (MS). Secretaria de Atenção Primária à Saúde. Perguntas Frequentes - Amamentação e COVID-19 [Internet]. 2020 [acessado 2022 set 30]. Disponível em: https://egestorab.saude.gov.br/image/?file=20200810_N_20200807NfinalFACAmamentacaoeCOVID1966649330922523577_ 5036660980636280742.pdf.
https://egestorab.saude.gov.br/image/?fi... , even puerperae suspected or positive for COVID-19 should continue breastfeeding their babies. Thus, PHC health teams should accompany these women in the puerperium, guiding them in safe breastfeeding under established protocols.

Besides the above, the postpartum follow-up by remote appointments faced technical and logistical difficulties, hindering a greater bond and reading the body language of the puerperae⁹9 Schindler-Ruwisch J, Phillips KE. Breastfeeding during a pandemic: The influence of COVID-19 on lactation services in the Northeastern United States. J Human Lacta 2021; 37(2):260-268..

Given this context, the present study aimed to understand the implications of the COVID-19 pandemic in breastfeeding and health promotion actions within primary care based on the perception of breastfeeding women.

Methodological procedures

This qualitative, descriptive, and exploratory study was developed according to the Consolidated Criteria for Reporting Qualitative Research (COREQ) precepts and based on the theoretical framework of the Interactive Theory of Breastfeeding (ITB), which concerns the aspects inherent to breastfeeding¹⁰10 Primo CC, Brandão MAG. Interactive theory of breastfeeding: creation and application of a middle-range theory. Rev Bras Enferm 2017; 70(6):1191-1198..

The ITB is a mid-range theory of nursing based on the components of the Conceptual Model of Interactive Open Systems by Imogene King. It emphasizes that systems are open, intercommunicating, and seek individual and group balance, where any change in one of the systems can have repercussions on the others. Thus, individuals are intended to preserve their health with their dynamic needs based on personal, interpersonal, and social interactive systems relating continuously to the environment. Among the concepts intertwined with such systems in the ITB, breastfeeding is seen as an interactive process between women, their children, and the environment¹¹11 King IM. Toward a theory for nursing: systems, concepts, process. New York: Delmar Publishers Inc; 1981..

The Interactive Theory of Breastfeeding describes, explains, and analyzes factors that influence breastfeeding initiation, maintenance, and termination. The theory provides elements that can predict the result and the dynamic and systematic interactivity of breastfeeding. It proposes eleven theoretical concepts: dynamic mother-child interaction; women’s biological conditions; children’s biological condition; women’s perception; children’s perception; woman’s body image; breastfeeding space; mother’s role; organizational systems to protect, promote and support breastfeeding; family and social authority; and women’s decision-making¹⁰10 Primo CC, Brandão MAG. Interactive theory of breastfeeding: creation and application of a middle-range theory. Rev Bras Enferm 2017; 70(6):1191-1198..

The study included 24 women linked to the assigned areas of three Family Health Units (USF) of Health District (DS) III of Recife, Pernambuco, purposely chosen. Breastfeeding mothers who had children from April 1 to September 30, 2020, and breastfed during the first year of the COVID-19 pandemic were selected. Those with compromised mental health during the data collection phase were excluded. The delimitation of this period was due to some routine care demands, such as childcare visits, which had restrictions due to the need to restructure the municipal health network¹²12 Governo Municipal de Recife. Protocolo de assistência e manejo clínico do novo coronavírus (Covid-19) na Atenção Primária à Saúde do município de Recife. Recife: Governo Municipal de Recife; 2020..

In the data collection process, together with the DS-III family health teams, children born in the first year of the pandemic, between the pre-established months, were identified. Then, the respective mothers’ profiles were mapped with the team’s professionals and complemented during the interview. Breastfeeding women were characterized by age group, the existence of a partner, employment type, whether they contracted COVID-19 during pregnancy, delivery, or postpartum, number of children, delivery type, and number of prenatal care visits.

Many activities have become remote for preventive reasons due to the pandemic setting, including a good part of scientific research actions¹³13 Governo Municipal de Recife. Protocolo de Retomada das Atividades e Serviços na Atenção Primária à Saúde do Recife. Recife: Governo Municipal de Recife; 2020.. Thus, data were collected from December 2021 to January 2022 through digital media audio-recorded interviews, via the multiplatform instant messaging application WhatsApp, with a mean duration of 35 minutes, and subsequent data transcription. The interviews were held through a semi-structured roadmap, with the following guiding questions: “Tell me about your experience with breastfeeding in this pandemic setting”; “In your perception, what factors facilitated your BF in this period, and what are the difficulties faced in BF?”; “Did you receive help from the USF health team after you arrived from the maternity ward?”.

Data production ended due to theoretical saturation when the corpus had thematic recurrences and achieved the proposed objective¹⁴14 Moser A, Korstiens I. Series: Practical guidance to qualitative research. Part 3: Sampling, data collection and analysis. Eur J Gen Pract 2018; 24(1):9-18..

The interviews were analyzed using Bardin’s content analysis technique¹⁵15 Bardin L. Análise do conteúdo. São Paulo: Edições 70; 2016.. An initial reading of the material was performed in the organization or pre-analysis stage, and the documents useful for the research were separated and the initial hypotheses formulated. Then, the obtained content was submitted to a detailed study to identify new record units, which were grouped into codes or thematic categories to respond to this study’s objectives. In the third phase of categorization, these nominal categories were organized to interpret the emerging results and search for the meaning of the messages. This is the time for intuition and reflective and critical analysis¹⁵15 Bardin L. Análise do conteúdo. São Paulo: Edições 70; 2016..

This study respected the ethical requirements under Resolution No. 466/2012, and all participants read and signed the Informed Consent Form. The interviews were randomly coded from P1 to P24.

Results

Twenty-four nursing mothers participated in the study. Most were aged 26 to 30, married, and had two or more children. Regarding the type of employment relationship, most were self-employed or worked from home.

Most women reported that the prenatal care visits were conducted satisfactorily despite the pandemic context, vaginal delivery prevailed, and most breastfeeding women adopted exclusive breastfeeding (EBF) for six months. Most respondents reported not being infected by COVID-19 during the pregnancy-puerperal period, and less than half had confirmed results through diagnostic tests.

Two thematic axes were prepared from the analysis of the empirical material: Repercussions of the pandemic on the promotion of breastfeeding; Weaknesses in health promotion and support for the mother-child binomial in primary care during the COVID-19 pandemic. The statements of the nursing mothers were presented in tables on each axis, with dialogue between them and the theoretical ITB concepts.

Axis 1 - Repercussions of the pandemic on the promotion of breastfeeding

The COVID-19 pandemic represented a moment of fear and insecurity during the pregnancy-puerperal period for breastfeeding women. Breastfeeding was permeated by different feelings, such as concern and anxiety regarding the possibility of transmitting COVID-19 to their babies. However, despite uncertainties, mothers showed knowledge of health protocols. They aimed to implement precautionary recommendations against the coronavirus: hand hygiene, mask use during breastfeeding, social distancing, and restricted visits to the mother-child binomial.

Due to this setting, some changes also occurred in women’s work. The home office work activity adopted by employers and self-employment allowed many breastfeeding women to breastfeed longer, which promoted breastfeeding during the pandemic. However, other women were fired from work during pregnancy or shortly after the end of maternity leave, which may have compromised their mental health and, consequently, adherence to BF or its continuity.

Another repercussion of the pandemic in promoting EBF up to six months was the early inclusion of infant formulas to complement or even replace breast milk due to the return to work, low milk production, cracks in the breasts, cultural and family influence, and women’s decision.

It is noteworthy that, even in the face of the difficulties and implications of the pandemic in the breastfeeding process and the peculiarities of the puerperal period, most breast-nursing mothers did not give up breastfeeding. The search for information and the desire to breastfeed were predominant for them to secure breast milk on demand, as per the data in Chart 1.

Axis 2 - Weaknesses in health promotion and support for the mother-child binomial in primary care during the COVID-19 pandemic

Breastfeeding is not exclusive to women but is influenced by the entire primary and secondary support network surrounding them. In this study, in the face of a pandemic setting, we observed that the most engaged support network for women comprised of family members. Health services did not provide enough guidance on the breastfeeding process, and PHC professionals did not perform home visits in the first postpartum week.

The online strategy of monitoring the breastfeeding mother and her child was adopted to mitigate the losses in breastfeeding and child monitoring arising from the lack of visits and face-to-face home visits. It adopted text messages and telephone calls. The findings indicate that this strategy included only some women and children. Moreover, children’s follow-up through childcare visits in primary care was also compromised as it started late and needed to be complying with the recommendations of the Ministry of Health. The low USF attendance resulted in poor child development follow-up in the first months of life, as shown in Chart 2.

Discussion

Caring for women in the pregnancy-puerperal cycle during the COVID-19 pandemic is challenging. It demands decisive action from health professionals in creating strategies that contribute to adequate and safe care during this period¹⁶16 Santos ALC, Santos LTR, Teles RM, Teles SCS, Freitas PA. Principais impactos gerados no manejo das gestantes durante o pré-natal frente a pandemia da Covid-19. RUNA [periódico na Internet]. 2021 [acessado 2022 set 30]. Disponível em: https://repositorio.animaeducacao.com.br/handle/ANIMA/14741.
https://repositorio.animaeducacao.com.br... .

The accounts of the women in this study reveal that mothers are concerned and insecure about transmitting the SARS-CoV-2 virus during breastfeeding. However, the virus’ presence in the breast milk of women positive for COVID-19¹⁷17 Martins-Filho PR, Santos VS, Santos HP. Amamentar ou não amamentar? Falta de evidências sobre a presença de SARS-CoV-2 no leite materno de gestantes com COVID-19. Rev Panam Salud Publica 2020; 44:e59. has not been proven. The insufficient knowledge about the coronavirus transmission through breast milk can influence the Interactive Theory of Breastfeeding concepts in women’s decision-making to continue breastfeeding, causing stress and interfering with the breastfeeding duration¹⁰10 Primo CC, Brandão MAG. Interactive theory of breastfeeding: creation and application of a middle-range theory. Rev Bras Enferm 2017; 70(6):1191-1198.. Furthermore, reported misinformation may be related to the failure of organizational systems to protect, promote, and support breastfeeding, and not only during motherhood¹⁰10 Primo CC, Brandão MAG. Interactive theory of breastfeeding: creation and application of a middle-range theory. Rev Bras Enferm 2017; 70(6):1191-1198..

Amidst the uncertainties, the fears generated during the pandemic made responsible bodies change breastfeeding care. However, it remained vigorously defended by the World Health Organization (WHO). According to Technical Note No. 10/2020, skin-to-skin contact (SSC) and breastfeeding can occur after performing hygiene care and adopting measures to prevent newborn contamination, such as cleaning the parturient (bath in the bed), and mask, cap, nightgown, and sheet change¹⁸18 Brasil. Ministério da Saúde (MS). Secretaria de Atenção Primária à Saúde. Nota Técnica n°10/2020-COCAM/CGCIVI/DAPES/SAPS/MS [Internet]. 2020 [acessado 2022 set 30]. Disponível em: https://saude.rs.gov.br/upload/arquivos/202006/03180219-nota-tecnica10-2020-cocamcgcividapessapsms-003.pdf.
https://saude.rs.gov.br/upload/arquivos/... ^,1919 Sociedade Brasileira de Pediatria (SBP). Recomendações para assistência ao recém-nascido na sala de parto de mãe com Covid-19 suspeita ou confirmada [Internet]. 2020 [acessado 2022 out 5]. Disponível em: https://www.sbp.com.br/fileadmin/user_upload /22422b-Nalerta-Assist_RN_SalaParto_de_mae_com_ COVID-19.pdf.
https://www.sbp.com.br/fileadmin/user_up... .

Considering that women’s environment is of great importance for better child development and the promotion of the mother-child bond, fear, and psychosocial disorders affected this construction, generating negative repercussions on the health of both. Furthermore, the COVID-19 pandemic produced stress and anxiety in pregnant women globally²⁰20 Fakari RF, Simbar M. Pandemia de coronavírus e preocupações na gravidez: uma carta ao editor. Arch Acad Emerg Med 2020; 8(1):e21..

In this context, health professionals can adopt interrelated ITB concepts that influence the breastfeeding process. Women’s decision-making is a dynamic behavioral process in which they choose to breastfeed, among other options offered, since they see themselves as a mother and family authority in society. However, these women’s stance weakened in the pandemic, limiting the follow-up of care to puerperae, causing conflict in the mother-child interaction¹⁰10 Primo CC, Brandão MAG. Interactive theory of breastfeeding: creation and application of a middle-range theory. Rev Bras Enferm 2017; 70(6):1191-1198..

We can also observe the weak relationship between family, community, and the State when identifying that women are often forced to work outside the home ahead of time due to financial necessity and, while included in the labor market, they remain with daily household responsibilities, no longer exclusively breastfeeding their children²¹21 Guiginski J, Wajnman S. A penalidade pela maternidade: participação e qualidade da inserção no mercado de trabalho das mulheres com filhos. Rev Bras Estud Pop 2019; 36:1-26..

With the COVID-19 pandemic, the type of work known as home office (or remote work) was established to reduce employees’ exposure to highly contaminated environments²²22 Garcia-Contreras R, Munoz-Chavez P, Valle-Cruz D, Ruvalcaba-Gomez EA, Becerra-Santiago JA. Teleworking in Times of COVID-19. Some Lessons for the Public Sector from the Emergent Implementation During the Pandemic Period: Teleworking in times of COVID-19 [Internet]. 2021 [acessado 2022 set 20]. Disponível em: https://dl.acm.org/doi/10.1145/3463677.3463700.
https://dl.acm.org/doi/10.1145/3463677.3... . With that, many women could continue their work and offer EBF until six months.

At home, a support network formed by the partner, the child’s grandmother, or other family members was a predictor of improved breastfeeding outcomes²³23 Emmott EH, Page AE, Myers S. Typologies of postnatal support and breastfeeding at two months in the UK. Soc Sci Med 2020; 246:112791..

On the other hand, not all women could work remotely and have a support network during the pandemic. They adopted infant formula in baby food. Therefore, these results show an articulation between the concepts of women’s and children’s perceptions, biological conditions of women and children, space for breastfeeding, and family and social authority. The latter brings in its definition the importance of valuing the concepts and perceptions of each member active in the breastfeeding process as a guide for the woman’s behavior¹⁰10 Primo CC, Brandão MAG. Interactive theory of breastfeeding: creation and application of a middle-range theory. Rev Bras Enferm 2017; 70(6):1191-1198..

Understanding the concept of breastfeeding space from the ITB perspective, its influence on breastfeeding, and its dependence on relationships and situations imposed by the personal, historical, and sociocultural context of women¹⁰10 Primo CC, Brandão MAG. Interactive theory of breastfeeding: creation and application of a middle-range theory. Rev Bras Enferm 2017; 70(6):1191-1198.^,2424 Primo CC, Mocelin HJS, Zavarize TB, Lima EFA, Lima RO, Brandão MAG. A percepção da mulher sobre os espaços para amamentar: suporte na teoria interativa de amamentação. REME Rev Min Enferm 2019; 23:e1261. is considered. Thus, while some mothers could breastfeed longer, others felt forced to stop before they were ready due to a lack of professional guidance, as some hospitals discharged mothers and their newborns early and limited visits and appointments, reducing specialized lactation care time, education, and technical assistance⁷7 Brown A, Shenker N. Experiences of breastfeeding during COVID-19: Lessons for future practical and emotional support. Maternal Child Nutr 2021; 17(1):e13088.^,2525 Spatz DL, Davanzo R, Müller JA, Powell R, Rigourd V, Yates A, Geddes DT, van Goudoever JB, Bode L. Promoting and protecting human milk and breastfeeding in a COVID-19 world. Front Pediatr 2021; 8:633700..

Restricted physical contact due to social distancing due to the pandemic, and the limited support by health services in PHC, also allowed and stimulated the search for other solutions to emerging hardships. Thus, due to different digital marketing strategies, different proposals for infant formulas emerged to replace or complement breast milk²⁶26 Piwoz EG, Huffman SL. The Impact of Marketing of Breast-Milk Substitutes on WHO-Recommended Breastfeeding Practices. Food Nutr Bull 2015; 36(4):373-386..

Among the reasons for early weaning is nipple trauma, which could be noticed and avoided by the health team if a greater follow-up in promoting BF during prenatal and puerperium care was in place. Knowing the benefits of breastfeeding can encourage its practice, even in the face of difficulties, and this emphasizes the importance of the health team in the prenatal, postpartum, and childcare follow-up²⁷27 Monteschio CAC, Gaíva MAM, Moreira MDS. The nurse faced with early weaning in child nursing consultations. Rev Bras Enferm 2015; 68(5):587-593..

The ITB addresses the dynamic mother-child-environment interaction as a condition for achieving satisfactory breastfeeding. Thus, the health team can use the theoretical concepts to guide healthcare, identifying the weaknesses in this interaction to collaborate with promoting breastfeeding continuity¹⁰10 Primo CC, Brandão MAG. Interactive theory of breastfeeding: creation and application of a middle-range theory. Rev Bras Enferm 2017; 70(6):1191-1198..

It is worth noting that an adequate support network is essential for this practice, especially in the first days of breastfeeding, after childbirth. However, this family and health team support for women was reduced²⁸28 Cirino FMSB, Aragão JB, Meyer G, Campos DS, Gryschek ALFPL, Nichiata LYI. Desafios da atenção primária no contexto da COVID-19: a experiência de Diadema, SP. Rev Bras Med Familia Comu 2021; 16(43):1-14. with social distancing. Even in the face of difficulties, we should recognize the most influential individuals in the nursing mother’s social network and understand the dynamic interaction of these people with women in the breastfeeding process¹⁰10 Primo CC, Brandão MAG. Interactive theory of breastfeeding: creation and application of a middle-range theory. Rev Bras Enferm 2017; 70(6):1191-1198..

The statements of breastfeeding women pointed out that the leading primary support network during the pandemic was limited to family members, and husbands and their mothers were more frequent. This result is corroborated by research conducted with Hispanic women residing in the United States, which indicated that 57% mentioned the partner as the primary support and 32% the mother²⁹29 Linares AM, Hall L, Ashford K. Psychometric testing of the Autonomy and Relatedness Inventory - Spanish Version. J Nurs Meas 2015; 23(1):27-37..

The support of partners/husbands is essential to successful breastfeeding. Their presence with the mother and baby, help with household chores, and baby care can ease the hardships experienced in breastfeeding³⁰30 Teston EF, Reis TS, Góis LM, Spigolon DN, Maran E, Marcon SS. Aleitamento materno: percepção do pai sobre seu papel. Rev Enferm Centro-Oeste Mineiro 2018; 8:e2723..

Another essential member of the support network for breastfeeding women is the PHC health team. It was necessary to reorganize the services and care provided to mitigate infection and better assist those already infected²⁶26 Piwoz EG, Huffman SL. The Impact of Marketing of Breast-Milk Substitutes on WHO-Recommended Breastfeeding Practices. Food Nutr Bull 2015; 36(4):373-386.^,3131 Fernandez M, Lotta G, Corrêa M. Desafios para a Atenção Primária à Saúde no Brasil: uma análise do trabalho das agentes comunitárias de saúde durante a pandemia de Covid-19. Trab Edu Saude 2021; 19:e00321153. during the COVID-19 pandemic, especially in the initial phase of coronavirus infections.

However, even with all the professionals’ efforts, breastfeeding women and childcare assistance were impaired since there needed to be a specific resizing plan to preserve assistance and reduce harm to breastfeeding women. Research carried out by Fiocruz throughout Brazil³²32 Fundação Oswaldo Cruz (Fiocruz). Pesquisa analisa o impacto da pandemia entre profissionais de saúde [Internet]. 2021 [acessado 2022 out 10]. Disponível em: https://portal.fiocruz.br/noticia/pesquisa-analisa-o-impacto-da-pandemia-entre-profissionais-de-saude#:~:text=Os%20dados%20indicam%20que%2043,a%20necessidade%20de%20improvisar%20equipamentos.
https://portal.fiocruz.br/noticia/pesqui... revealed that almost 50% of workers admitted to being overworked during this global health crisis, working more than 40 hours a week, besides professional staff shortage. As a result, the supply and quality of care for women were compromised during this period.

Promoting breastfeeding, when initiated during pregnancy and continued in the puerperal period, supports the prevalence of longer BF duration. In the meantime, we understand the need and relevance of puerperal visits by PHC professionals, respecting all protocols⁵5 Paixão GPN, Campos LM, Carneiro JB, Fraga CDS. A solidão materna diante das novas orientações em tempos de SARS-COV-2: um recorte brasileiro. Rev Gaucha Enferm 2021; 42:1-13..

Given the pandemic setting, telemedicine emerges as a strategy for continuity of care for the mother-child binomial. The virtual puerperal visit aimed to facilitate the approximation between patients and health professionals due to the restrictive pandemic measures, although it did not replace the face-to-face appointment. Despite the limitations inherent to this care model, it is possible to conduct health promotion and prevention activities, favoring essential aspects such as neonatal screening, timely vaccination, and establishing BF³³33 Moraes MMS, Rocha EMS. Visita puerperal virtual: estratégia educacional em tempos de pandemia de Covid-19. Rev Docenc Ens Sup 2022; 12:1-20..

Thus, it is essential to emphasize that telehealth assists women in the pregnancy-puerperal cycle. It has been a promising and sustainable tool, not only for the pandemic context. However, the present study revealed that this type of care was incipient, heterogeneous, and without standardized provision of services, mainly due to restricted access to the Internet by most of the Brazilian population³⁴34 Núcleo de Informação e Coordenação do Ponto BR. Influência da COVID 19 na qualidade da internet no Brasil [Internet]. 2020 [acessado 2022 out 10]. Disponível em: https://www.ceptro.br/assets/publicacoes/pdf/Relatorio_Influencia_Covid-19_Qualidade_Internet_Brasil.pdf.
https://www.ceptro.br/assets/publicacoes... .

We should also note how challenging childcare was for health professionals and mothers during the COVID-19 pandemic, given that social distancing and isolation hindered mothers’ access to USFs, and mothers were encouraged to take care of the child at home, taking them to health services only in case of illness, which goes against health promotion guidelines³⁵35 Pacheco ST, Nunes MDR, Victória JZ, Xavier WS, Silva JA, Costa CIA. Recomendações para o cuidado à criança frente ao novo coronavírus. Cogitare Enferm 2020; 25:e73554..

Due to the restrictions expressed in current protocols¹⁰10 Primo CC, Brandão MAG. Interactive theory of breastfeeding: creation and application of a middle-range theory. Rev Bras Enferm 2017; 70(6):1191-1198.^,3636 Governo do Estado de Pernambuco. Protocolo de atendimento na atenção primária no período de pandemia COVID-19 no estado de Pernambuco. Pernambuco: Governo do Estado de Pernambuco; 2020., this study revealed the difficulty of immediate puerperal follow-up in the pandemic and the limitations for starting childcare visits at the USF in Recife, temporarily suspended, with priority given to at-risk children care.

Thus, the COVID-19 pandemic has side effects that extend beyond those of direct viral infection. Although the coronavirus does not cause severe direct effects on the child population, its indirect effects are relevant and still unknown³⁷37 Zar HJ, Dawa J, Fischer GB, Castro-Rodriguez JA. Challenges of COVID-19 in children in low- and middle-income countries Paediatric Respiratory. Paediatric Respiratory Rev 2020; 35:70-74..

Final considerations

The pandemic affected the quality of breastfeeding for women. However, although most women maintained exclusive breastfeeding in this study, this process altered the mental health of those who lived under tension, anguish, and anxiety about contracting SARS-CoV-2 during the critical moments of the pandemic in 2020 and 2021.

Regarding the emotional and affective mother-baby bond, social distancing has been experienced as a positive experience for preserving breastfeeding, as it promoted greater contact time between mothers who had the guaranteed right to remote work (home office) or even among self-employed women. On the other hand, the pandemic has contributed to unemployment, which can promote increased vulnerabilities and social inequalities.

The women’s support network was weakened by concerns about infection during the first year of the pandemic, with the more effective participation of the primary support network, consisting of the husband and mother of the nursing mother. This support was aggravated due to the lack of specific guidelines for the PHC team as a secondary support network since this team had to prioritize care for people who are sick or symptomatic due to COVID-19.

It is noteworthy that the Interactive Theory of Breastfeeding was feasible to analyze the reality of the study participants, showing its potential for practice with breastfeeding women, considering that its concepts are consistent with what women experience. However, the negligible number of studies with data analyzed in the light of ITB could have improved the comparison of our results. Thus, further studies related to the theory and its components are recommended to confirm its value for promoting BF and making healthcare more scientific.

A limitation of this study is the low number of participants, which may not represent the reality of Brazilian women in breastfeeding and the recent nature of the application of the ITB, and new research in different social contexts is required to subsidize a more in-depth theoretical analysis on the impact of COVID-19 in the different Brazilian settings.

References

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