Lulie R O SusinI; Elsa R J GiuglianiII; Suzane C KummerIII
IDepartamento de Patologia. Fundação Universidade do Rio Grande. Rio Grande, RS, Brasil
IIDepartamento de Pediatria e Puericultura. Faculdade de Medicina. Universidade Federal do Rio Grande do Sul. Porto Alegre, RS, Brasil
IIISecretaria Municipal de Porto Alegre. Porto Alegre, RS, Brasil
OBJECTIVE: To assess the influence of grandmothers on breastfeeding practices.
METHODS: This was a prospective study on 601 mothers of normal babies born in a university hospital in the city of Porto Alegre, State of Rio Grande do Sul. Data were collected in the maternity ward and at home, one, two, four and six months after delivery, by means of interviews with the mothers. Information about grandmothers was obtained at the time of the first home visit. Multiple logistic regression was used to test associations between variables related to the grandmothers and the prevalence of breastfeeding.
RESULTS: Abandonment of exclusive breastfeeding within the first month was significantly associated with maternal or paternal grandmothers who advised that water or tea (OR=2.2 and 1.8, respectively) and other kinds of milk (OR=4.5 and 1.9, respectively) should be given. Abandonment of breastfeeding within the first six months was associated with maternal and paternal grandmothers who advised that other kinds of milk (OR=2.4 and 2.1, respectively) should be given. Non-daily contact with the maternal grandmother was a protective factor for maintaining breastfeeding until six months.
CONCLUSIONS: Grandmothers may have a negative influence on breastfeeding, both on its duration and its exclusivity. This information could be useful in the planning of strategies for promoting breastfeeding.
Keywords: Breast feeding. Lactation. Health knowledge, attitudes, practice. Breastfeeding, exclusive. Breastfeedings practice, influence.
There is no longer any doubt today that breastfeeding is the best way of feeding and interacting with infants. The World Health Organization (WHO) recommends that children should be exclusively breastfed during the first six months and should continue, with supplementation, up to the age of two years or more.* Despite this, breastfeeding rates in Brazil are still low, although national surveys have indicated a rising trend. The median duration of breastfeeding was 2.5 months in 1973/747 and seven months in 1996.12 The latest national survey, carried out in October 1999 in Brazilian state capitals and in the Federal District, with the exception of Rio de Janeiro, confirmed this trend, showing a median duration of breastfeeding of 10 months.11 The median duration of exclusive breastfeeding, however, was only 23 days.
Despite the importance of breastfeeding for the child, mother, family and society,2 breastfeeding rates are low in Brazil, especially exclusive breastfeeding. To modify this situation, actions for encouraging this practice are needed. These must take into consideration factors that interfere in breastfeeding, since it is known that even though breastfeeding is biologically determined, it is influenced by social, psychological and cultural factors. Among such factors, there are the opinions and encouragement given by people who are around the mother, including the child's maternal and/or paternal grandmothers. In the United States, a study on a low-income population demonstrated that maternal grandmothers were the people with the greatest influence on the feeding of infants.10 Another study5 indicated that the maternal grandmother was the most important source of information about breastfeeding for the majority of Puerto Rican and Cuban women.
The influence of grandmothers on breastfeeding may favor it or cause difficulties. In Texas, United States, the maternal grandmother was considered to be the most important source of support for beginning breastfeeding, among women of Mexican origin.4 In Canada, it was found that women who received support from their mothers and from the child's father, and also those who had previously decided to breastfeed, before becoming pregnant, breastfed their children for a longer period of time.9 In a study carried out in Africa, grandmothers encouraged exclusive breastfeeding and thought that supplementation with water was unnecessary and harmful to the child's health. They believed that such supplementation was recommended by healthcare professionals.1
On the other hand, a study carried out in Porto Alegre, State of Rio Grande do Sul, brought out a suspicion that grandmothers could have a negative influence on the duration of breastfeeding. According to this study, the absence of help from a family member in the home was a protective factor against the abandonment of breastfeeding before the age of four months (RR=0.6).6 In Natal, State of Rio Grande do Norte, the prevalence of exclusive breastfeeding was significantly lower among children with grandmothers present in the family group, in comparison with families from which the grandmothers were absent.3
The objective of the present research was to assess the influence of grandmothers during the breastfeeding period, by means of studying some characteristics of the grandmothers and their relationships with the prevalence of breastfeeding during the child's first six months of life.
This study was conducted in Porto Alegre, State of Rio Grande do Sul, in a university general hospital that does 4,000 deliveries per year. Its clientele are of different socioeconomic levels, with a predominance of individuals of lower purchasing power who are users of the Brazilian National Health System (Sistema Único de Saúde - SUS). The present article deals with part of the data coming from the study, which had the overall objective of assessing the impact of an intervention for encouraging breastfeeding, directed towards mothers and fathers.13 During the sample selection period, all the mothers of normal newborns were considered to be eligible for inclusion in the study (n=654), provided that the infant had a birth weight of greater than or equal to 2,500 g, was together with the mother in the maternity ward and had started to breastfeed, and provided that the mother was living together with the father. Of these mothers, seven (1.1%) were not included in the study because they refused to participate, or the child's father refused permission, and 46 (7.1%) could not be included in the sample because the father was not available for interview and intervention. Thus, the sample was made up of 601 mother-child pairs.
After the mothers gave their consent to participate in the study and sign an informed consent statement, they were interviewed while still in the maternity ward, with the objective of obtaining some personal information about the father, children and family. Information relating to the feeding practices adopted for the child were obtained by means of interviews with the mothers in their homes, at the ends of the first, second, fourth and sixth months of the child's life. The visits stopped before the sixth month if breastfeeding was abandoned. The data were collected using standardized questionnaires that were drawn up for the interviews in the maternity ward and homes.
The information on the maternal and paternal grandmothers was obtained at the time of the first home visit, when the children were completing their first month. The following topics were included: frequency of contact with the grandmothers; whether the grandmother though that it was good that the mother was breastfeeding; whether the grandmother had advised and/or offered water and/or tea and another type of milk for the child; type of participation by the grandmothers in breastfeeding; and whether the grandmothers' opinions were influencing the mother's decisions regarding breastfeeding.
At the time of the first home visit, 571 mothers (95.0%) were located for interviewing; 547 mothers (91.0%) continued to participate in the study until its conclusion. Over the follow-up period, there were 38 losses (6.3%) and 16 exclusions (2.7%). The losses occurred for the following reasons: change of address - 18; mother and/or father could not be reached - 10; the family was away, traveling, without a known return date - six; and refusal by the mother and/or father to continue in the study - four. The exclusions occurred because of separation of the parents (15 cases) and the death of one child.
There were no statistically significant differences between the characteristics of the 53 mothers who were not included in the study (initial losses) and the 601 mothers who made up the initial sample. For this, the characteristics analyzed were the type of delivery, sex of the newborn, per capita income, marital status, age, schooling, color, prenatal attendance and duration of breastfeeding for previous children.
The breastfeeding categories utilized were those recommended by WHO.14 A child was considered to be breastfed when it was receiving the mother's milk every day, independent of whether it was receiving supplementation or not. The child was considered to be exclusively breastfed when it only received the mother's milk, without any solid or liquid supplementation.
For the analysis of the data, the Epi Info 5.1 and SPSS for Windows software was utilized. Initially, bivariate analysis was performed (chi-squared test), with calculation of the odds ratios and their respective confidence intervals, for investigating associations between selected variables and the abandonment of exclusive breastfeeding within the first month and the abandonment of breastfeeding within the first six months. Multiple analysis was subsequently performed, by means of logistic regression, to verify the influence of some of the mother's variables (age, schooling, skin color, per capita income and number of previous children) that had been shown to have a relationship with the duration of breastfeeding in studies performed on the same population,8 in associations between breastfeeding practice and variables related to the grandmothers.
Since part of the sample was submitted to an intervention for promoting breastfeeding in the maternity ward, the group of such mothers was added to the model utilized in the logistic regression. This intervention consisted of watching a video containing basic information on breastfeeding, followed by an open discussion and the distribution of a leaflet. The sample was thus divided into three groups, according to the intervention: control group, without intervention; a group in which the mothers received the intervention; and a group in which the mothers and fathers underwent the intervention.
The present study was approved by the Health Research Ethics Committee of Hospital de Clínicas of Porto Alegre.
Table 1 presents the characteristics of the sample. A majority of the mothers had white skin color (58.8%), were aged between 20 and 30 years (58.3%) and had five to eight years of schooling (45.7%), one to three children (50.4%) and a per capita income of between 0.6 and 1.9 minimum salaries (50.8%). Approximately 87.0% of the maternal and paternal grandmothers were alive.
The study showed that a majority of the mothers had frequent contact (a minimum of once a week) with their mothers (67.9%) and mothers-in-law (56.9%). For almost 40.0% of the mothers, there was daily contact with their respective mothers, while 30% had daily contact with their mothers-in-law. Most of the mothers reported that the maternal and paternal grandmothers thought it was good that they were breastfeeding (93.2% and 84.4%, respectively), but less than half of them admitted that the grandmothers had an influence on their decisions regarding breastfeeding (43.3% and 32.4%, respectively). According to the mothers, the maternal grandmothers helped during the breastfeeding period more frequently than did the paternal grandmothers (59.5% and 47.0%, respectively). A little over half of the maternal grandmothers (56.0%) and paternal grandmothers (54.0%) advise that water and/or tea should be given. A smaller proportion of the maternal and paternal grandmothers took the initiative to offer these liquids to the child (17.3% and 11.3%, respectively). The use of another milk was less recommended (13.5% and 12.3%) and put into practice (4.8% and 4.0%) by the maternal and paternal grandmothers, respectively.
Tables 2 and 3 present the results from the bivariate and multivariate analyses for testing associations between variables relating to the grandmothers and the abandonment of exclusive breastfeeding within the first month of life and the abandonment of breastfeeding within the first six months. Independent of the mother's characteristics, the fact that the grandmothers recommended water and/or teas significantly increased the risk that the child might not be exclusively breastfed at the end of the first month (by 2.22 times when the maternal grandmother advised this and by 1.83 times when such advice came from the paternal grandmother). When the maternal grandmother advised the use of another milk, the risk that the child might not be exclusively breastfed at the end of the first month increased by 4.51 times. In relation to abandoning breastfeeding within the first six months, the risk increased by 2.39 times. When the advice to give another milk came from the paternal grandmother, these risks increased by 1.86 times for exclusive breastfeeding abandoned within the first months and 2.05 times for breastfeeding abandoned within the first six months. The mothers who reported that the paternal grandmother did not think it was good that they were breastfeeding, or did not know of the grandmother's opinion, had practically twice the chance of stopping breastfeeding within the first six months. Non-daily contact with the maternal grandmothers favored breastfeeding until the child was six months old, but this did not occur in relation to the paternal grandmothers.
The bivariate analysis for testing whether more constant presence of one of the grandparents was related to absence of the mother from the home (which might have an influence on the duration of breastfeeding) showed that there was no association between frequency of contact with the grandparents and mothers starting to work by the end of the first, second, fourth or sixth month (p=0.20-0.83).
Although some studies have indicated that grandmothers are the people who most influence10 and support4,9 mothers during breastfeeding, such studies have not specified the type of support and influence that grandmothers have. Nor have they assessed the impact of such support or influence on the practice of breastfeeding. The present study is the first to quantify the influence of some factors related to grandmothers in the practice of breastfeeding. The suspicion that grandmothers can have a negative influence on the duration of breastfeeding has been confirmed. Independent of the mother's age, skin color, schooling, per capita income, number of children and having received intervention in the maternity ward or not, the mothers with daily contact with their own mothers had a greater chance of abandoning breastfeeding during the first six months after the birth of the child. On the other hand, more frequent contact with the paternal grandparents did not significantly affect the duration of breastfeeding. However, it seems that the mother's perception of whether the mother-in-law approves of breastfeeding is important in maintaining it, since the mothers who reported that the mother-in-law was not in favor of breastfeeding, or that they did not know of the mother-in-law's opinion, had almost twice the chance of abandoning breastfeeding within the first six months.
Two previous studies carried out in Brazil3,6 had already raised suspicions that closer contact with the grandparents might be unfavorable in relation to breastfeeding. The first,6 carried out in Porto Alegre, observed that mothers who reported that they had help at home from a relative had a 67% greater risk of abandoning breastfeeding within four months. On the other hand, having help from a domestic employee was shown to be a protection factor for breastfeeding. Since that study had not specified the type of relative, the authors speculated that grandmothers might, in most cases, have been the relative referred to. The study by Andrade & Taddei3 showed an association between the presence of grandmothers in the family group and shorter duration of exclusive breastfeeding. However, these authors did not define "presence of grandmothers".
In the present study, no association was found between more frequent contact with the grandmothers and abandonment of exclusive breastfeeding within the first month. However, the fact that both the maternal and paternal grandmothers advised that water, teas or another milk should be used contributed significantly to the abandonment of exclusive breastfeeding within the first month.
For the majority of the families studied, there was frequent contact with the grandmothers. For economic reasons, many families were continuing to share the dwelling (or the site) after the formation of a new family. This fact cannot be neglected when planning strategies for promoting breastfeeding. In addition to this, it is important to take into consideration that a significant percentage of grandmothers (around half of them) were already, within the first month, advising that water and/or teas should be given. This attitude may contribute towards the abandonment of exclusive breastfeeding. More than 75% of the grandmothers in the sample studied had their children during the 1960s or 1970s, a time when breastfeeding, and especially exclusive breastfeeding, was not so highly valued. The breastfeeding rates were very low, the use of waters and teas was recommended by pediatricians, and the belief that breast milk was "weak milk" or "little milk" held sway. Therefore, in many situations, the grandmothers are just transmitting to their daughters or daughters-in-law their own experience with breastfeeding, believing it to be the most appropriate.
There needs to be caution in generalizing the results from the present research. The population studied probably represents the Brazilian urban population that has lower purchasing power. Among this population, it is very common for grandmothers to be close at hand at the time of the birth of a new child in the family and, possibly, to exert influence over the mother's decisions regarding how to feed the child. It is possible that, in other populations, the influence exerted by grandmothers would be different to what was found in the present study. For example, in Lesotho, in southern Africa, grandmothers stimulate exclusive breastfeeding, since they consider that supplementation with water is unnecessary and harmful to the child's health.1
Although the present study revealed an association between daily contact with the maternal grandmother and shorter duration of breastfeeding, it has not elucidated the factors involved in this relationship. It is probable that the grandmothers are passing on their experiences from 20 or 30 years ago, which go against the present recommendations for the feeding practices for infants. But it is also possible that the mothers who have daily contact with their mothers or mothers-in-law delegate to them part of their roles as mothers, and that this is reflected in shorter duration of breastfeeding. Specifically delineated studies would be needed to investigate this question.
In conclusion, the results from the present study indicate that grandmothers may have a negative influence on breastfeeding, regarding both its duration and its exclusivity. Since breastfeeding is a process that is highly influenced by culture, promotional strategies need to be developed within a cultural context that is appropriate for the target population. Thus, on the basis of the results from the present study, it can be stated that it is important to include grandmothers in programs for promoting breastfeeding. Through this, they would be able to lay out their beliefs and feelings in relation to breastfeeding and receive new information. Grandmothers would thus be better prepared to exert a positive influence, so as to ensure successful breastfeeding by their daughters or daughters-in-law.
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15. World Health Organization. Nutrition and infant feeding. Disponível em: http.//www.who.int/child-adol-health/NUTRITION/infant_exclusive.htm. [9 nov 2004]
Lulie Rosane Odeh Susin
Rua José de Carvalho Estima, 79 Jardim do Sol
96216-070 Rio Grande, RS, Brasil
Received on 5/8/2003. Reviewed on: 6/5/2004. Approved on 13/7/2004.
Fundo de Incentivo à Pesquisa e Eventos do Hospital de Clínicas de Porto Alegre (FIPE/HCPA - Grant n. 046/94).
Based on doctoral thesis presented within the postgraduate program in medical sciences (pediatrics) of the Federal University of Rio Grande do Sul, in 2003.
* World Health Organization. Nutrition and infant feeding. Available at: http.//www.who.int/child-adol-health/NUTRITION/infant_exclusive.htm. [2004 Nov 9]