Abstract

Introduction

In the early 90's, the “Baby Friendly Hospital Initiative” (BFHI) strategy was created, mobilizing staff from units with obstetric services to change hospital practices and routines in order to promote, protect, and support breastfeeding. Therefore, the “Ten Steps to Successful Breastfeeding”¹1. World Health Organization/UNICEF: The global criteria for the Baby-Friendly Initiative . WHO/UNICEF; 1992were established. In 1992, in Brazil, the Ministry of Health and the Group for Children Rights Defense adopted the BFHI as a strategy to increase breastfeeding rates²2. Rea MF. Reflexões sobre a amamentação no Brasil: de como passamos a 10 meses de duração. Cad Saúde Pública 2003; 19 (S1): 37-45..

Step 4 of BFHI advocates “putting babies in direct contact with the mother soon after birth for at least an hour and encourage mothers to identify if the baby is ready to breastfeed, offering help if needed”³3. Fundo das Nações Unidas para a Infância/Organização Mundial de Saúde. Iniciativa Hospital Amigo da Criança: revista atualizada e ampliada para o cuidado integrado. Série A, Normas e Manuais Técnicos. Brasília; 2009.. Breastfeeding should be provided even in the delivery or surgery room, once both mother and child are well, enjoying the moment when mother and baby are alert and interacting. The early skin to skin contact between mother and baby is also associated with a better interaction between the dyad, longer duration of breastfeeding⁴4. Anderson GC, Moore E, Hepworth J, Bergman N. Early skin to skin contact for mothers and their healthy newborn infants. (Cochrane Review) In: Cochrane Database of Systematic Reviews , Issue 3, 2007. Oxford: Update Software., higher levels of blood glucose, better temperature control of the newborn, and the disappearance of the child's crying when held by his or her mother^{5, 6}6. Moore ER, Anderson GC, Bergman N. Early skin-to-skin contact for mothers and their healthy newborn infants. Cochrane Database Syst Rev 2007; 18:(3):CD003519. ^{, 7}7. Ayala AG, Lopez IB, Muñoz HC. Efecto Del contacto materno precoz en el recien nacido a termino. Rev Pediatria (Santiago) 1993: 127-34.Moreover, there is an indication of an association between early breastfeeding and exclusive breastfeeding ⁸8. Silva MB, Albernaz EP, Mascarenhas MLW, Silveira RB. Influencia do apoio à amamentação sobre o aleitamento materno exclusivo dos bebês no primeiro mês de vida e nascidos na cidade de Pelotas, Rio Grande do Sul, Brasil. Rev Bras Saude Matern Infant 2008; 8 (3): 275-84. .

Brazilian studies have shown that the prevalence of breastfeeding in the first hour of life is around 50% in Baby Friendly Hospitals^{9- 10}10. Silveira RB, Albernaz E, Zuccheto LM, Fatores associados ao início da amamentação em uma cidade do sul do Brasil. Rev Bras Saúde Matern Infant 2008; 8(1): 35-43. , however, in hospitals non-accredited by this initiative the practice is less common, reaching close to one third of babies¹⁰10. Silveira RB, Albernaz E, Zuccheto LM, Fatores associados ao início da amamentação em uma cidade do sul do Brasil. Rev Bras Saúde Matern Infant 2008; 8(1): 35-43. ^{, 11}11. Boccolini CS, Carvalho ML, de Oliveira MIC, Leal MC, Carvalho MS. Fatores que interferem no tempo entre o nascimento e a primeira mamada. Cad Saúde Pública 2008; 24(11): 2681-94.. Few studies have investigated factors associated with breastfeeding in the first hours of life in our environment.⁹9. Oliveira MIC, Silva KS, Gomes-Jr SC, Fonseca VM. Resultado do teste rápido anti-HIV após o parto: uma ameaça à amamentação ao nascimento. Rev Saúde Pública 2010; 44(1): 60-9.

10. Silveira RB, Albernaz E, Zuccheto LM, Fatores associados ao início da amamentação em uma cidade do sul do Brasil. Rev Bras Saúde Matern Infant 2008; 8(1): 35-43.

11. Boccolini CS, Carvalho ML, de Oliveira MIC, Leal MC, Carvalho MS. Fatores que interferem no tempo entre o nascimento e a primeira mamada. Cad Saúde Pública 2008; 24(11): 2681-94.

12. 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. ^{- 13}13. Vieira TO, Vieira GO, Giugliani ER, Martins CC, Silva LR. Determinants of breastfeeding initiation within the first hour of life in a Brazilian population: cross-sectional study. BMC Public Health 2010; 10: 760. The purposes of this work are to understand how BFHI Step 4 is applied in a high risk maternity, to investigate the prevalence of breastfeeding in the first hour following birth, and the factors affecting this practice.

Methods

This is a cross-sectional study conducted from June 15 to September 11, 2009 in a public maternity hospital at a general hospital of the Ministry of Health, part of the High Risk Pregnancy System of Rio de Janeiro.

The study conducted a sample calculation out of the total deliveries made in 2007 in this maternity, approximately 2,700 deliveries, which correspond to 225 deliveries/month (statistics from the Department of Obstetrics). To test the main assumptions chosen in this study, based on the outcome, “non-breastfeeding in the first hour of life”, the study used, as the main exposure variable, the cesarean delivery, prevalence of 62.2% of non-breastfeeding in the first hour and a relative risk = 1.3 (95%CI: 1.15-1.46)⁹9. Oliveira MIC, Silva KS, Gomes-Jr SC, Fonseca VM. Resultado do teste rápido anti-HIV após o parto: uma ameaça à amamentação ao nascimento. Rev Saúde Pública 2010; 44(1): 60-9.. Taking in account a 95%CI and an 80% sample power, a sample of 402 women was calculated. There were 577 births during the study period, with 38.6% of cesarean deliveries. The study used the following inclusion criteria: mother hospitalized in rooming-in with her newborn and the birth taking place at the unit. The exclusion criteria included patients who had newborns with gestational age less than 37 weeks, according to the New Ballard score¹⁴14. Ballard JL, Khoury JC, Wedig K, Wang L, Eilers-Ealsman BL, Lipp R. New Ballard score, expanded to include extremely premature infants. J Pediatr 1991; 119(3): 417-23.registered by the pediatrician in the book of records of the delivery room; APGAR less than seven in the fifth minute of life and/or some abnormality; situations that could hinder or contraindicate breastfeeding at birth, such as the use of illicit drugs by the mother or HIV positive¹⁵15. Paim BS, Silva ACP, Labrea MGA. Amamentação e HIV/AIDS: uma revisão. Bol Saúde , Porto Alegre, jan/jun 2008, 22(1): 67-74.. After applying these criteria, 403 women remained with childbirth occurred in the period, who were interviewed using a semi-structured questionnaire elaborated according to instrument used in other research⁹9. Oliveira MIC, Silva KS, Gomes-Jr SC, Fonseca VM. Resultado do teste rápido anti-HIV após o parto: uma ameaça à amamentação ao nascimento. Rev Saúde Pública 2010; 44(1): 60-9., comprising identification data, socio-demographic and reproductive profile, and prenatal and childbirth care. The schedule of hospital routines was used to help mothers recall the time of first breastfeeding.

The database was built by EPIINFO® 3.5 and the analyses were held by SPSS15® .

The outcome studied was non-breastfeeding in the first hour of life, categorized in up to 60 minutes and after 60 minutes of birth; the exposure variables were:

• •

  maternal socio-demographic characteristics (age, education, self-reported skin color, work, and number of long term assets),

• •

  reproductive characteristics (presence of a partner, parity, and planned pregnancy),

• •

  characteristics of prenatal care (accomplishment, number of appointments; starting quarter, professional approach on breastfeeding; location breastfeeding was addressed; guidance on non-bottle use),

• •

  characteristics of delivery assistance (type of delivery, baby birth weight, help for breastfeeding at the time of delivery, type of assistance provided, knowledge about breastfeeding in the delivery room, staff asked if the mother wanted to put the baby in the breast, place of occurrence of the first breastfeeding, women consider that staff heard what she said about breastfeeding her child, and satisfaction with hospital services).

The Prevalence Ratio, with its respective confidence interval of 95%, was estimated from model with log log complementary link function. The linking function is preferred for binary events likely to occur very frequent, such as the one observed. The variables with p-value ≤ 0.20 in the bivariate analysis were considered in the modeling process.

In the final model, all variables with a 5% significance level were considered¹⁶.

The study was approved by the Committee for Ethics in Research of Bonsucesso General Hospital (Case No 15/09, approved on 05.08.2009). The women participated in the study after signing the consent form in accordance with Resolution No. 196 of October 10 1996 (CNS 196/96).

We state that, in this work, there was no connection or financing agreement among the authors and companies or people who may have interests in the material addressed in the paper.

Results

The age of the mothers ranged from 13 to 46 years, once 24.3% were adolescents. About 45.1% of women did not conclude elementary school and 26.7% considered themselves black. Just over half (51.9%) of them were working mothers, and 73.2% had more than five long-term assets. About 88.3% of mothers had partners; 33.3% were primiparous and 70.0% had not planned the pregnancy. Among their socio-economic and reproductive features, only the black color (PR = 0.80) and multiparity were protective factors to non-breastfeeding in the first hour of life ( Table 1 ). The group of non-black women consisted of 20.1% who reported themselves as white, 45% mulatto, 5.5% yellow, and 2.5% indigenous.

Underwent prenatal care 93.1% of the women (52.4% began in the first quarter of pregnancy and 55.6% received information on breastfeeding during this period), 56.6% went to 6 to 12 appointments. Undergoing prenatal care and guidance on breastfeeding in group proved to be protective against non-breastfeeding in the first hour of life ( Table 2 ).

The prevalence of breastfeeding in the first hour of life was 43.9% (n = 177). Were breastfed after the first hour of life 72.1% of the babies delivered by caesarean section and 47.5% of the babies born by normal delivery. The normal delivery, the appropriate birthweight, help for breastfeeding at labor time, especially when the type of help was to facilitate the newborn's contact with the mother's breast, and if the mother was questioned about her desire to put her baby on her breast showed protection against the outcome non-breastfeeding in the first hour ( Table 3 ).

In the multivariate model ( Table 4 ), the variables that were statistically significant protective factors for non-breastfeeding in the first hour of life were: non-black women (PR = 0.62), multiparity (PR = 0.66), undergoing pre-natal care (PR= 0.23), normal delivery (PR = 0.41), proper birth weight (PR = 0.31) and help from staff to breastfeed in the delivery room (PR = 0.51).

Discussion

The interviewed mothers that underwent prenatal care were strongly protected regarding breastfeeding their children in the first hour of life. The prenatal care should include comprehensive health care, disease prevention, and commitment to quality of life of the dyad. Moreover, in a research conducted in Guinea-Bissau¹⁷17. Gunnlaugsson G, Da Silva MC, Smedmann L. Determinants of delayed initiation of breatfeeding: a community and hospital study from Guinea-Bissau. Int J Epidemiol 1992; 21(5): 935-40., one of the factors that contributed to the delay of first breastfeeding was the absence of undergoing prenatal care (p = 0.0001). Vieira et al¹³13. Vieira TO, Vieira GO, Giugliani ER, Martins CC, Silva LR. Determinants of breastfeeding initiation within the first hour of life in a Brazilian population: cross-sectional study. BMC Public Health 2010; 10: 760., in 2010, reported an association between breastfeeding in the first hour of life and having received guidance on the advantages of breastfeeding in the prenatal period, indicating that this care facilitates the preparation for breastfeeding.

Our results showed that multiparous women were more protected against non-breastfeeding in the first hour, similar to the results found in a research conducted in the hospital network of the city of Rio de Janeiro¹¹11. Boccolini CS, Carvalho ML, de Oliveira MIC, Leal MC, Carvalho MS. Fatores que interferem no tempo entre o nascimento e a primeira mamada. Cad Saúde Pública 2008; 24(11): 2681-94., suggesting that the larger the number of children, the faster the first breastfeeding occurs, possibly because of the doubts and insecurities of primiparous women. However, some international studies showed no association between parity and breastfeeding within one hour¹⁸18. Ogunlesi.TA. Maternal Socio-Demographic Factors Influencing the Initiation and Exclusivity of Breastfeeding in a Nigerian Semi-Urban Setting. Child Health J 2010; 14: 459-65.,¹⁹19. Awi DD, Alikor EA. Barriers to timely initiation of breastfeeding among mothers of healthy full-term babies who deliver at the University of Port Harcourt Teaching Hospital. Niger J Clin Pract 2006; 9(1):57-64..

Moreover, socio-economic factors such as education and skin color showed contradictory results in the literature. In our study, consistent with other findings⁹9. Oliveira MIC, Silva KS, Gomes-Jr SC, Fonseca VM. Resultado do teste rápido anti-HIV após o parto: uma ameaça à amamentação ao nascimento. Rev Saúde Pública 2010; 44(1): 60-9.also in Rio de Janeiro, women who reported their skin color as non-black were protected concerning breastfeeding in the first hour of life. However, research conducted in Pelotas, by Silveira et al¹⁰10. Silveira RB, Albernaz E, Zuccheto LM, Fatores associados ao início da amamentação em uma cidade do sul do Brasil. Rev Bras Saúde Matern Infant 2008; 8(1): 35-43.pointed non-white mothers breastfeeding earlier. In this study, and in a study by Boccolini et al, at 47 maternity hospitals of Rio de Janeiro¹²12. 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., education was not associated with the outcome, while in Pelotas¹⁰mothers with more education were those who started breastfeeding later, and these mothers, who were white and with more education, were the ones most subjected to caesarean sections.

According to studies reported, in the African Brazilian population²⁰20. Ministério da Saúde. Secretaria de Políticas de Saúde. Manual de Doenças mais importantes, por razões étnicas, na população brasileira Afro-Descendentes. Série A. Normas e Manuais Técnicos 2001, no. 123., the population group with black or brown skin color, from the economic and social standpoint, is the poorer, less educated, and living in areas with low sanitation treatment. A research conducted with mothers, in maternity hospitals in Rio de Janeiro between 1999 and 2001, found inequalities that have occurred from access to prenatal care up to labor for black patients²¹21. Leal MC, Gama SGN, Cunha CB. Desigualdades raciais sóciodemográficas e na assistência ao pré-natal e ao parto, 1999-2001. Rev Saúde Pública 2005; 39(1): 100-7.. In our research, conducted in a hospital from the Brazilin public healthcare system (SUS), different from the population study of Pelotas¹⁰10. Silveira RB, Albernaz E, Zuccheto LM, Fatores associados ao início da amamentação em uma cidade do sul do Brasil. Rev Bras Saúde Matern Infant 2008; 8(1): 35-43., the fact that black women have shown less prevalence of breastfeeding in the first hour is one more negative indicator to penalties already imposed on these women at time of delivery.

The cesarean section, in the present investigation, was responsible for a high incidence of late breastfeeding. Literature has consistently shown it to be a risk factor to breastfeeding at birth⁹9. Oliveira MIC, Silva KS, Gomes-Jr SC, Fonseca VM. Resultado do teste rápido anti-HIV após o parto: uma ameaça à amamentação ao nascimento. Rev Saúde Pública 2010; 44(1): 60-9.

10. Silveira RB, Albernaz E, Zuccheto LM, Fatores associados ao início da amamentação em uma cidade do sul do Brasil. Rev Bras Saúde Matern Infant 2008; 8(1): 35-43.

11. Boccolini CS, Carvalho ML, de Oliveira MIC, Leal MC, Carvalho MS. Fatores que interferem no tempo entre o nascimento e a primeira mamada. Cad Saúde Pública 2008; 24(11): 2681-94.

12. 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.-¹³13. Vieira TO, Vieira GO, Giugliani ER, Martins CC, Silva LR. Determinants of breastfeeding initiation within the first hour of life in a Brazilian population: cross-sectional study. BMC Public Health 2010; 10: 760., being recognized as such by the World Health Organization itself, advocating that at baby-friendly hospitals, at least 80% of mothers with normal birth and 50% of those subjected to caesarean section should receive help to place the baby in skin to skin contact to start breastfeeding³3. Fundo das Nações Unidas para a Infância/Organização Mundial de Saúde. Iniciativa Hospital Amigo da Criança: revista atualizada e ampliada para o cuidado integrado. Série A, Normas e Manuais Técnicos. Brasília; 2009.. In normal delivery, protector for the outcome, the more active participation of women and the greater possibilities of the baby placed naked in direct contact with her body in the first minutes after birth, can help her to recognize on the child the signs of being ready to breastfeed.

The prevalence found for breastfeeding in the first hour (43.9%) was very close to that shown by a recent population survey in Brazil (43%)²²22. Ministério da Saúde. Pesquisa Nacional de Demografia e Saúde 2006. Portal da saúde . Disponível em http:www.saude.gov.br (Acessado em 06 de março de 2009).
http:www.saude.gov.br... . Although the hospital studied is in qualifying process to be approved as Baby-Friendly, its staff still lacks uniformity in delivery care. Routine procedures performed with healthy newborns, such as the suction of the airways and pharynx, measuring length and weight and body care (bathing) may interfere with breastfeeding at birth, resulting in loss of effective contact between mother and baby. These immediate unnecessary interferences on the newborn are common practices despite the recommendation that in the delivery room, mother and child should not be separated unless indicated by a medical reason³3. Fundo das Nações Unidas para a Infância/Organização Mundial de Saúde. Iniciativa Hospital Amigo da Criança: revista atualizada e ampliada para o cuidado integrado. Série A, Normas e Manuais Técnicos. Brasília; 2009.. The rates of breastfeeding in the first hour of life practiced for women with normal delivery (52.5%) and cesarean section (27.9%) are still far from what BFHI³3. Fundo das Nações Unidas para a Infância/Organização Mundial de Saúde. Iniciativa Hospital Amigo da Criança: revista atualizada e ampliada para o cuidado integrado. Série A, Normas e Manuais Técnicos. Brasília; 2009.established and WHO/UNICEF¹1. World Health Organization/UNICEF: The global criteria for the Baby-Friendly Initiative . WHO/UNICEF; 1992recommended.

An even lower prevalence of breastfeeding in the first hour was found in a study that investigated factors that interfered with this practice in a representative sample of maternity hospitals in the city of Rio de Janeiro, once only 26.4% of mothers of newborns with low and medium risk born from normal delivery, and 5.8% of those submitted to cesarean section breastfed in the first hour of life.¹²12. 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.

Less than half of the women knew it was possible to breastfeed in the delivery room (43.4%), but even in these cases the professionals were not questioned or their help requested. The practice of Step 4 is still little applied by the hospital staff, and for 85.1% of the mothers, it was not asked if they wanted to breastfeed at that time. The Ministry of Health (2005)²³23. Ministério da Saúde. Manual Normativo para Profissionais de Saúde de Maternidades, Referência para Mulheres que Não Podem Amamentar . Brasília: Ministério da Saúde; 2005.indicates that the mother-baby bond must be ensured through skin contact, even in mothers who cannot breastfeed, immediately after pediatric care, when needed in the specific situation. At this important moment, the woman is undervalued in her emotions, and the main concern is with the birth of a healthy child²⁴24. Dias MAB e Deslandes SF. Humanização da Assistência ao Parto no Serviço Público: reflexão sobre desafios profissionais nos caminhos de sua implementação In: Deslandes SF (org.). Humanização dos Cuidados em Saúde: conceitos, dilemas e práticas . Rio de Janeiro: Editora FioCruz; 2006; pp. 351-66.. There must be ongoing education for professionals to improve work processes, with more positive results.

A solution concerning the reduction of first breastfeeding time, found in Nigeria, was the presence of a companion during labor, especially in large hospitals²⁵25. Morhason-Bello IO, Adedokun BO, Ojengbede OA. Social support during childbirth as a catalyst for early breastfeeding initiation for first-time Nigerian mothers. Int Breastfeed J 2009; 4: 16.. This action has been thought of in our country, and the law of the companion was regulated by Administrative Rule 2418 of December 2^nd2005²⁶26. Ministério da Saúde, Portaria Nº 2418/GM de 2 de dezembro de 2005..

Letting the woman know that she can breastfeed her baby in the delivery room, asking if she wants to do so and helping her to hold her baby, and to identify whether it is time to breastfeed the baby, fundamental help from the health staff, are actions that involve assistance to newborns and are recognized as having significance in the protection of breastfeeding in the first hour of life³3. Fundo das Nações Unidas para a Infância/Organização Mundial de Saúde. Iniciativa Hospital Amigo da Criança: revista atualizada e ampliada para o cuidado integrado. Série A, Normas e Manuais Técnicos. Brasília; 2009..

We conclude that BFHI Step 4 was performed to less than half of the clientele, at levels well below those recommended by WHO/UNICEF¹1. World Health Organization/UNICEF: The global criteria for the Baby-Friendly Initiative . WHO/UNICEF; 1992. Besides maternal socio-economic and reproductive protection factors, such as non-black skin color and multiparity, undergoing pre-natal care, normal delivery, appropriate birthweight of the newborn, and being offered help to breastfeed at delivery favored breastfeeding the first hour of life.

Acknowledgment: To Valentim Magalhães, whose scholarship from the Scientific Initiation Institutional Program (PIBIC) enabled his assistance in applying the questionnaires and to Professor Dr Saint Clair Gomes Júnior for the relevant assistance with statistical analysis.

References

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