Breastfeeding and weaning : a look on the experiences of nurses who are mothers

One aimed to understand the experience of children’s breastfeeding and weaning by nurses who are mothers. Descriptive, exploratory study with a qualitative approach, performed in Maringá, PA, Brazil, with 10 nurses who are mothers, selected by the snowball method between November 2011 and January 2012. Data were collected through semi-structured interviews and analyzed using the content analysis technique. Three categories emerged: understanding the process of pregnancy and breastfeeding in the life context of nurses who are mothers; Outlining the weaning process from the perspective of nurses who are mothers; Breastfeeding and the professional demands of nurses who are mothers: motivations and strategies used for weaning. It was considered that returning to work was the main reason for early weaning, resulting in feelings of frustration by nurses who are mothers for not following the recommendation of exclusive breastfeeding up to the sixth month, in terms of personal experience. Descriptors: Mothers; Breast Feeding; Weaning; Nursing.


Introduction
Breast milk is a complete food, appropriate to the needs of children in their first months of life.It contains vitamins and water, besides having antiinfective properties and growth factors.It presents adequate level of protein and minerals that are easily digested, as well as lipids, with sufficient amount of essential fatty acids, lipase for digestion, iron in small quantities and with a good absorption (1) .
Besides the known advantages for the baby, breastfeeding also offers many benefits for the mother, such as reduced risks of breast, ovarian and uterine cancer, and osteoporosis prevention.The act of the baby's sucking relieves the mother from the discomfort of full and heavy breasts, promoting the secretion of prolactin (responsible for milk production and ovulation inhibition), also acting as a contraceptive method (2) .Moreover, it is noteworthy that the act of breastfeeding is also important for the consolidation of emotional bonds between mother and child (3) .
Although breastfeeding is a natural human process, it is common to find these days, mothers with difficulties in this process, which could result, ultimately, in early weaning (4) .
Besides the organic effects (physiological, nutritional and immunological) of the act of nonbreastfeeding, it is highlighted the deprivation of mother and son of experiencing a unique touch, in terms of consolidation of intimacy and emotional bonds that characterize this unique experience of motherhood.
The reasons that can lead to early weaning are: mother's organic dysfunction, socioeconomic level, changes in family structure, a problem with the baby, educational level, urbanization, conditions of delivery, maternal age, lack of encouragement from the spouse and relatives, maternal employment and disinterest from the mother to breastfeed; corroborating the thesis of multifactorial causes, by the association between maternal/newborn factors and the context of family insertion (5) .
Given all the arguments that emphasize the importance of breastfeeding, as well as the agreement of experts in the maternal and child area in relation to their priority status in the field of primary care, it is understandable the pressure level that health professionals, especially nurses, experience in dealing with their own motherhood and in breastfeeding their children.
It is known that historically, the role and the practice of nursing in the Brazilian context, especially in the realm of public health, has always been linked to an educational-assistance action.Thus, the own educational process of nurses emphasizes their responsibilities regarding the orientation of the patients, as part of the comprehensive health care to the health of the various sectors of the population.
That being so, not surprisingly, the exigency regarding breastfeeding is even bigger on these professionals, since they are responsible in their various areas of expertise, for the guidance and encouragement of this practice with mothers.Thus, when they do not achieve success in the process of breastfeeding their own children, nurses who are mothers commonly experience feelings of frustration and helplessness.
Despite the recognition of the importance of breastfeeding, it is known that the prevalence of early weaning is a worldwide problem.Findings from the II Research about the Prevalence of Breastfeeding in the Brazilian capitals and the Federal District conducted in 2008 show that the average duration of exclusive breastfeeding was 54 days and the average duration of breastfeeding was 341 days (6) .
Given these considerations, and due to the scarcity of studies addressing the issue of breastfeeding in the perspective of mothers who are nurses in the national scenario, this study aimed to understand the experience of breastfeeding and weaning with the children of mothers who are nurses.

Method
This is a descriptive exploratory study with qualitative approach, performed in Maringá, located in the northwestern region of the Brazilian State of Paraná, with a total area of 488 km 2 and a population of 357,007 inhabitants (7) .The research subjects were 10 nurses who are mothers with a single child and that were acting professionally.In this study, women with children of pre-school age were included.The age limit of the children has been set to enable the mothers interviewed, the most detailed description of their recent experiences related to breastfeeding.
For being a qualitative study, one chose to use the purposive sample for convenience, to fetch and select cases that are "rich" in information about the topic, and most likely to answer the central question of the study.In this study, the purposive sample was sampling with criteria, ie, one selected individuals most likely to provide information relevant to the issue, according to some predefined criteria considered important to the understanding of the subject (8) .
The process of selection of mothers, professional nurses, happened through the method of chains or "snowball" (9) , so that each participant was asked to indicate someone from her professional or social life to join the research.One considered as primary subject the one who was contacted and approached first regarding the interest in participating in the study.From this one, other contacts were made by phone or in person.Only after expressions of interest in participating, they were asked to schedule an interview, according to date, time and place of their convenience/preference, ranging from their own residence and their workplace.
Data collection occurred from November 2011 to January 2012, and was done through interviews, using a semi-structured script, with the following central question: When and how was it for you the process of breastfeeding and later weaning of your child?Additionally, the script had questions with more objective character, for the characterization of the subjects; and a second part, with open-ended questions focused on the development of the central theme of the study.
The data analysis was based on the content analysis technique, which consists in the phases of pre-analysis, exploration of the material and treatment results (10) .
The data were collected without predetermining the number of participating subjects, as the number of subjects was determined by data saturation and by achieving objectives.The reports that were relevant to the thematic development were recorded and later transcribed in order to preserve the accuracy of the information.To ensure the anonymity of participants, they were identified by the word 'interview' and Arabic numbers. The

Results
The age of the subjects ranged from 29 to 46 years old (average 33 years old), and the age of the participants at the birth of the child was between 25 and 39 years of age (average 30 years of age).Most participants were married, two mothers had a stable union and two were divorced.
Regarding their education, all the participants had, besides the undergraduate nursing course at least one post-graduation course (specialization).The monthly family income ranged from R$ 1,800.00 to R$ 15,000.00(average of R$ 8,260.00),five families had a monthly income lower than R$ 5,000.00.
The age of the children during the study ranged from eight months to six years of age (average of three years of age).Regarding sex, half of the sample was composed of girls and half of boys.
From the process of approach of the study's central theme, and in order to contemplate the proposed analytical objective, three categories emerged, which will be discussed below.

Understanding the process of pregnancy and breastfeeding in the life context of nurses who are mothers
The planning of pregnancy was mentioned by most nurses who are mothers interviewed, so that only three couples did not plan the pregnancy.The most mentioned reason by mothers to justify the choice of pregnancy at that particular point in their lives was a financial and professional stability.When we chose to have a child, we decided that we were going to be father and mother, that we would not have a nanny (Interview 8).It was all planned in my life for (child's name) to came at the right time.Of course if I had known it was so nice to have a baby, having children, I would have had one before.I would not have waited to get stable with a house, a job!Because I think it did not disturb me at all (Interview 3).
In spite of planning their pregnancy, all participants acted professionally during their pregnancy and childbirth, and two mothers described having two jobs during this period.
Three mothers breastfed exclusively until the sixth month of their children's life, and the reasons mentioned for this achievement was returning to work after the baby was six months old and having the help of the husband and of a nanny, who took the child to the mother's workplace, in breastfeeding time.The duration of breastfeeding in the children of the study was determined by the need of the mother to return to work, after using the maternity leave.Thus, the period of exclusive breastfeeding varied from four to six months (average and mode of five months), and of breastfeeding from four to 28 months (average of 13.5 months).I got a maternity leave, of four months, I stayed four months away and two more months, as I had accumulated vacations, then I stayed six months with him.I was the one who took care of him (interview 5).
It was possible to notice a bigger variation between the respondents concerning the duration of breastfeeding, so that two mothers breastfed for less than six months; two, from seven to twelve months; five mothers breastfed until the child was between 12 and 24 months old; and one of them breastfed for more than 24 months.The baby's age at the time of the mother's return to work ranged from three to nine months old (average of five months old), and most babies were between four and six months old in accordance with the duration of the maternity leave.
Among mothers who could not maintain exclusive breastfeeding until the recommended minimum age, the following reasons for the early introduction of foods were: difficulties with logistics, due to return to work and the interruption of exclusive breastfeeding at the fourth month, due to the reduction or absence of milk production.It was very difficult, especially with breastfeeding.He did not accept any other milk ... I took my milk and he did not accept it on a spoon or in a cup: nothing, nothing, nothing (Interview 2).I had to go back to work before, so I could not breastfeed her.I had to take my milk and leave it at home... but with that my milk started drying (Interview 6).

Delineating the process of weaning from the perspective of nurses who are mothers
Besides the numerous advantages of breastfeeding, whether in its biological and nutritional sphere, either in terms of its impact on the process of creation of the bond between mother and child, their role in the process of identification with the exercise of the maternal role it can be summarized as follows: In the first months I think breastfeeding was vital for me to feel like a mother, to be able to have an intimate contact with my son (Interview 4).
By failing to breastfeed their children exclusively before the sixth month of life, nurses who are mothers reported the occurrence of feelings of profound sadness and frustration: It was too bad, because I did not accept "not breastfeeding".At first I did not accept it!I wanted to breastfeed, but I suffered too, my chest cracked, it was a torture!Before, I thought everything would be good, I prepared myself to breastfeed, but then everything went wrong.I still wanted to be breastfeeding (Interview 3).It was traumatic especially because we are from the health area.We create all that question of breastfeeding, we have a big expectation, throughout pregnancy, I did all the preparation of the breast, nipple and then I had a crack, I had everything I could not have (Interview 9).
This study also showed reports that describe the feeling of frustration due to the necessity of early food introduction: It was horrible, disappointing, because I work as a teacher in the subject of child health, and having to stop was not easy.This happened because I had to go back to work before completing six months ... I cried a lot, because I wanted her to stay in the chest until two years old, but with the introduction of other foods ... she started to refuse the chest... (Interview 6).
A negative aspect of this experience, which was emphasized by mothers during the interviews, was the memory of physical fatigue experienced by them during breastfeeding, especially at night.The increase in physical fatigue happened after returning to work, since the process of reconciling breastfeeding to work schedules and rest of the mothers was not always successful.
The need for weaning, due to the new functions assumed by mothers, generates an initial feeling of guilt: but I felt a little guilty for having to stop, because... as I had a lot of milk, I had that deplete the milk.So I felt terrible sorry for seeing all that milk being thrown away, my heart ached (Interview 1).At first it is complicated, it gives the impression you're not giving the child something that it's her right...But then I understood that it was the best for me and the best for her (Interview 10).The possibility of sharing child care may improve the success of more prolonged exclusive breastfeeding: at breastfeeding times, for example, my husband left his job, took my son, he and the nanny, and took him to my workplace for me to breastfeed, and also at night, as the distance was about 15-20 minutes, until I drove home and came back, there was not enough time.Other days it was my mother-in-law who stayed with him, so my husband left earlier from school and brought him to breastfeed (Interview 7).
Apart from the family support, another key factor for the success or failure of this practice is connected to the working conditions of nurses who are mothers: When I returned to work, nobody from the company talked to me, explaining to me what rights I had as a mother while I was breastfeeding (Interview 6).I had no support, that right we have of 15 minutes was not worth it because I was in a hospital, then there is all that concern about hospital infection until I could get home, take a shower so I could nurse her, I would have already spent an hour and 15 minutes (Interview 6).

Breastfeeding and the professional demands of nurses who are mothers: motivations and strategies used for weaning
From the analysis process of the interviewees' reports, it could be inferred that the return to work was an important milestone to make decisions about breastfeeding and to regulate family routines regarding the baby's care.
The return to the professional activity occurred when the average age of the children was five months old, and it was considered as a determining factor for the introduction of complementary foods before the child was six months old: I had the maternity leave, at that time it was four months, I got a medical certificate for another month, I returned to work when she was five months old.Then I started to introduce fruit and water (Interview 4).I breastfed exclusively until five months or so, because I had to go back to work, so I had to introduce baby food and fruit (Interview 8).Until the fifth month or so because I had to go back to work, I started trying to introduce a bottle, but she did not want her bottle, she did not want a cup, she wanted nothing, it was very difficult, it could be milk from the breast or formula milk, she didn't want any of them (Interview 10).
The period of maternity leave shorter than the recommended period for exclusive breastfeeding became a problem for many mothers to carry on this practice in a satisfactory way, leading to early introduction of complementary foods.It is worth remembering that at the birth of these women's children, maternity leave was still 120 days.
Mothers who stopped breastfeeding in the fourth month of the baby's life attributed early weaning to the fact that "the milk had dried" even with the use of drugs to increase milk production: I nursed exclusively only until four months, not because I wanted to, but because my milk was gone, vanished, I came here in the milk bank, took medication to get it back, but I could not have it back (Interview

3). It was very complicated the question of breastfeeding, I had to take medication to increase my milk production, but it didn't work, the milk started drying, drying, and five months after, I didn't have any more milk (Interview 9).
The time of weaning was considered by the mothers of the study as a very difficult and complex event in the family life.The process of detachment was painful, because it was a contact between me and her, a moment only ours, without involving anyone else.Besides, there was the physical problem of weaning and the breast ingurgitating... (Interview 4).It was complicated.Very complicated, because he wanted to nurse!So, at that time, I had already tried several times to take it out, but there's always that thing of feeling sorry, especially at night... (Interview 7).On the day we took it out, it was terrible, very difficult.He cried a lot, then I cried too.And he asked ... and I had milk!It's difficult.

But from the moment I decided to take it out, I thought: well it is for his own good, for the family's good, because everyone was too tired (Interview 8).
It is noticed in the reports, references to the time of breastfeeding as a unique mother and baby moment, vital to strengthen the emotional bond between them.
In addition to the emotional issue, the abandonment of breastfeeding imposes to mothers practical difficulties and the need to find strategies for weaning.Mothers reported the adoption of physical 'distance' during this phase, which contributes to the worsening of feelings of anxiety and stress of the binomial: It was difficult because we had to get far from each other.My mother, my mother-in-law and my husband were the only ones who took her in their arms, gave her a kiss, played with her, but I tried to stay farther (Interview 1).She got sad, she had to go stay at my mother's because she was older, she stayed there for a week in order to forget...She came back and asked me.And I said "oh no, there's no more," but I felt that she suffered and I also suffered a lot (Interview 4).I started saying that it was bruised, I covered my breast with adhesive tape, every day I had a Band-Aid or tape on my breast, and it was like this... after two or three days, she did not ask for it any more (Interview 7).

Discussion
The importance of breastfeeding is a paradigm that accompanies all the process of nurses' professional training and, in this perspective it is often valued by most of these professionals.
"Feeling like a mother" appears as a condition to which are connected several attitudes that outline the symbolism of this experience so remarkable in a woman's life.In this context, the figure of the woman who breastfeeds her child emerges as an undisputed proof of the full exercise of her maternal role.
It was observed in the reports that mothers feel frustrated regarding breastfeeding as a result of these created and unrealized expectations.Such expectations are delineated on the basis of scientific knowledge and on the actions recommended by the Ministry of Health regarding the attention in this area.Results found in a study conducted in São Paulo corroborate this finding (11) .
Another study claims that when breastfeeding is not done the way it was conceived, the dream of breastfeeding becomes uncertain in women's lives, because if the experience is not positive, it is perceived as suffering (12) .
The need for early introduction of food in children's care led women in the study to a crisis of roles, for this attitude is faced as incongruous between their professional practice, determined by their values and beliefs, which emphasize the importance of exclusive breastfeeding until the child's six months of age; and on the other hand, the inability of accomplish this guidance in their personal experience of being a mother.
Besides the knowledge gotten during the undergraduate course, it is known that nurses are the most involved professionals with the orientation activities of women in the process of pregnancy and puerperium.Although the attention to women is a multidisciplinary assignment, due to a closer relationship and contact with the pregnant woman, the nurse usually has the responsibility of guiding the woman in their doubts regarding breastfeeding and other health topics.In this sense the fact of not being able to decide for exclusive breastfeeding up to the sixth month, due to their return to work, or because of other obstacles, end up generating a lot of negative feelings during this experience.
In addition, it was evidenced in the study the fatigue generated in mothers during breastfeeding, especially at night.Some authors suggest that the stress in such conditions influence early weaning, so that it starts to represent the only alternative to solve the "problem" (1,13) .
In spite of this justification, early weaning created feelings of guilt on these women, mainly because they are people who have "the care" as the main object of their professional life.
The guilt feelings experienced by mothers may be attributed to the bond formed between mother and child as well as the lack of an adequate preparation of the mothers to cope with weaning.Breastfeeding strengthens the emotional bond between mother and child, providing an intimate moment of love, care and affection.This fact is reported by authors as a contributing factor to maintain breastfeeding for longer periods (14) .
It is also noticed that, although the participants in this study have a privileged body of knowledge about the importance of breast milk, referring satisfaction in the accomplishment of this practice, they point out several difficulties in maintaining it for an appropriate period.Authors have observed the same result in nursing mothers who, although recognizing the benefits of breast milk, had difficulties in continuing the process of breastfeeding (11,15) .It is therefore concluded that, prior knowledge about breastfeeding and its importance, does not constitute an element that can isolatedly ensure its effective practice.It is noteworthy that social support to mothers can contribute to the success of this practice.This support from family/friends is mentioned by mothers as a paramount point (11) .
Besides the family support, another key factor in the success or failure of breastfeeding is connected to the working conditions of nurses who are mothers.Thus, although this practice is ensured by Article 396 of the Consolidation of Labor Laws, many women are still unaware of their rights, and did not receive from their employers adequate guidance about it.According to this law, working mothers have the right to two special breaks of half an hour each, during the workday, so that they can breastfeed their children.
It must be emphasized that, in addition to information about the rights related to the maintenance of breastfeeding, other factors influence the final decision and the possibility of its implementation, which includes considering the existence of supporting infrastructure (day care center) within these mothers' workplaces, and also the peculiarities of the work or function performed by these professionals.
The period of maternity leave influences directly on the more prolonged exclusive breastfeeding in the lives of these women.It should be highlighted that, although in 2009 maternity leaves have risen from 120 to 180 days (Law No. 11,770), the decision of adopting it or not was up to each company (16) .In Paraná, also in 2009, Law No. 16,176 was enacted, which increased maternity leave for state public servants to 180 days.
A study conducted in Hong Kong shows that the return to work was the second important factor in the early weaning of its sample, present in 31% of the study participants (17) .This finding corroborates other studies on the topic (1.13) .
In this sense the return to work influences the lack of milk in the mother, leading to an early weaning.This condition arises from the conjunction of two factors: discontinuing the routine of breastfeeding, which leads to reduced milk production, associated with the introduction of artificial milk, which mothers use because of insufficient milk production (17) .
Mothers preferred to stop the practice of breastfeeding through getting far from children, having the support to family members to facilitate the process.However, this way of action is not appropriate for the occasion of weaning, as pointed out by the authors (18) .For them, weaning should occur gradually, so that mother and baby adjust, and that the process becomes easier.Furthermore, distracting the children, delaying feedings, replacing breast milk with solid foods, avoiding staying in places that used to be used to breastfeed, shortening the sessions of breastfeeding, replacing the "sucking" for "playing" are efficient strategies (18) .
When weaning occurs in a peaceful and progressive way and without sudden interruptions, it is possible the continuity of raising children without introducing bottles or pacifiers, and it "may allow babies to gradually start 'releasing' the strong bond with mothers " (18:135) , since physical contact provided by breastfeeding is intense due to the daily proximity between the binomial (19) .

Final Considerations
The return to work and the difficulty to manage their functions was the main reason mentioned by women in this study for early weaning of their children, thus revealing as harmful factors to breastfeeding and especially exclusive breastfeeding until the sixth months of a baby's life.
The knowledge acquired during their undergraduate courses and from their practice as health professionals about breastfeeding and its importance, does not constitute an element that can alone ensure its effective exercise in the lives of the women from this study.It is necessary the presence of a social support network for the mother, which collaborates to face the conflicting situations that may arise regarding infant care, particularly concerning the continued breastfeeding after returning to work and thus facilitating this process, so idealized by these mothers.
Given this finding, it is suggested a special look concerning the implementation of programs to encourage breastfeeding by institutions and companies, in order to allow mothers to continue breastfeeding for as long as possible.Furthermore, this study leads us to reflect on the maternal role, the family's support, the desire to have a child, and above all, the difficulties experienced by nurses who are mothers outside their personal reality of motherhood, as opposed with the task of taking care inherent to the nursing profession.
We can also conclude the need for studies that address the theme of the experiences of mothers and children in relation to weaning, about the main measures used in this situation and the aspects that can influence this process, so that weaning happens in a smoother and less traumatic way.Further studies on this theme can support alternatives to the difficulties and vulnerabilities in the breastfeeding process experienced by the mother/family.

Collaborations
Rodrigues BC contributed to the study design, data collection, analysis and writing of the article.Pelloso SM, França LCR and Ichisato SMT contributed to the data analysis, drafting and final revision of the article.Higarashi IH contributed in the orientation of the research, drafting and final revision of the article.
In the first two weeks, he cried until I got home about noon.So I had to make a deal to leave in the middle of the morning, at lunch and in the middle of the afternoon... then I worked overtime, so that I could go home to breastfeed him.So it was very difficult (Interview 2).It was exhausting to breastfeed after I went back to work, she asked to nurse at night.I needed to rest and she wanted to nurse.If I stayed there, she would cry the same way and I would not sleep.So I just gave her my breast (Interview 4).The day she was at my mother's, she nursed an entire bottle and slept the whole night!The day she was with me, she kept hung on my breast all night.And she neither slept nor let me sleep... (Interview 10).
research was discussed and approved by the Permanent Committee of Ethics in Research Involving Human Subjects from the State University of Maringa, under opinion No 263/2011.