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Conteúdo (article):

Fatores associados à continuidade do aleitamento materno por 12 meses ou mais em mulheres trabalhadoras de um hospital geral
Factors associated with breastfeeding continuation for 12 months or more amongworking mothersin a general hospital

Autores:
Michele Saraiva Mendes, Programa de Pós Graduação em Saúde da Criança e do Adolescente – Universidade Federal do Rio Grande do Sul, michele.mendes@yahoo.com.br, orcid 0000.0002.3240.4339
Monique Schorn, Programa de Pós Graduação em Saúde da Criança e do Adolescente – Universidade Federal do Rio Grande do Sul, mo_schorn@yahoo.com.br, orcid 0000.0002.0258.5052
Lilian Cordova do Espírito Santo, Departamento de Enfermagem Materno Infantil – Universidade Federal do Rio Grande do Sul, espiritosantolilian@gmail.com, orcid 0000.0002.2577.9079
Luciana Dias Oliveira, Departamento de Nutrição – Universidade Federal do Rio Grande do Sul, dialu73@hotmail.com, orcid 0000.0002.3438.0668
Elsa Regina Justo Giugliani, Programa de Pós Graduação em Saúde da Criança e do Adolescente – Universidade Federal do Rio Grande do Sul, elsag@terra.com.br, orcid 0000.0001.6569.6473


RESUMO
Objetivo: identificar fatores associados à continuidade da amamentação por 12 meses ou mais em mulheres trabalhadoras. Método: estudo transversal realizado por meio de entrevista com 251 trabalhadoras de um hospital, com filhos biológicos entre 12 e 36 meses de idade, não gemelares e sem doença que afetasse a amamentação, e amamentando quando do seu retorno ao trabalho. Para a associação entre a continuidade da amamentação e as variáveis de exposição utilizou-se a regressão multivariável de Poisson. Resultados: Apenas uma variável relacionada ao local de trabalho da mulher mostrou associação significativa com o desfecho. Trabalhar durante o dia aumentou em 37% a prevalência da amamentação por 12 meses ou mais. Os fatores não relacionados ao trabalho da mulher que mostraram associação positiva com o desfecho: mãe sem curso superior, experiência de amamentação superior a 12 meses; criança não receber outro leite quando a mãe retornou ao trabalho e não ter usado chupeta. Por outro lado, maior idade da mãe, maior idade gestacional, apoio do cuidador da criança e apoio profissional na amamentação associaram-se negativamente ao desfecho. Conclusão: fatores não relacionados diretamente ao trabalho materno tiveram maior participação na continuidade da amamentação por 12 meses ou mais.
DESCRITORES: Aleitamento materno. Trabalho feminino. Fatores de risco.

ABSTRACT
Objective: to identify factors associated with breastfeeding continuation for at least 12 months among working mothers ina hospital in the south of Brazil. Method: we conducted a cross-sectional study, interviewing 251 women whobreastfed after returning to work. Eligibility criteriaincluded non-twinbiological children aged between 12 and 36 monthsand the absence of an illness (mother and/or child)that could affect breastfeeding. The association between breastfeeding continuationand the exposure variables was tested using Poisson multivariate regression. Results: only one work-related variable showed a significant association with the outcome. Working only during the day increased the prevalence of BF continuationfor at least 12 months by 37%. The following non-work-related factors showed a positive association with the outcome: mothers withoutacollege degree; mothers with at least 12 months’ prior breastfeeding experience; child not given milks other than breast milk when the mother returned to work, and not using a pacifier. The following variables showed a negative association with the outcome:older maternal age;older gestational age; mother receiving support from the child’s caregiver;and mother receiving professional breastfeeding support. Conclusion: non-work-related factorshad a greater influence onbreastfeeding continuation for at least 12 months among working mothers.
KEYWORDS: Breastfeeding. Working mothers. Risk factors.

INTRODUCTION
In view of the benefits of breastfeeding (BF) for the health of children and mothers1-3, the prevention ofearly breastfeeding cessationis essential, even when the mother expresses the wish to breast feed for longer.
One of the multiple reasons for early interruption of BF, particularlyexclusive breastfeeding (EBF), ismaternal employment4-6. In this regard, studies show that measures supporting the maintenance of breastfeedingafterwomen’s return to work have a positive impact on BF continuation. These measures include flexible working hours, breastfeeding or milk expression breaks, appropriate facilities for expressing and storing milk, support from employersand work colleagues7, and child care near or at the workplace6.
A nationwide survey in Brazil8showed that 26.8% of working women with children under six months exclusively breastfed, compared to 53.4% of women on maternity leave and 43.9% of women who did not work. With regard to women with children under 12 months, 81.2% of women who did not workwere breastfeeding, compared to 65% of working women, thus demonstrating the impact of maternal employmentonBF rates.
Support for breastfeedingat the workplacehas been shown to be an important factor influencing BF continuationafter return to work. Despite thefact thatmaternal employmentis an important risk factor forearly breastfeeding cessation, few studies on this topic have been published, especially in Brazil. Little is therefore known about the barriers and facilitators forBF continuationafterreturn to work. Nevertheless, our understandingof the factors that influence breastfeedingbyworking mothers isvery relevantto theplanning of actions aimed at extending the duration of BFamong this population. Therefore, the aim of this study was to identify factors associated with BF continuationfor at least 12 monthsamongworking womenin a large general hospital, with emphasis on work-related factors.

MATERIALS AND METHODS
We conducted a cross-sectional study with 251 female staff of a large university hospital in Porto Alegre in the south of Brazil. The data were collected betweenJune 2016 and July 2017.
The hospital has around 6,000 staff, most of whom are womenofchildbearing age. The hospital offers the following conditions and facilities for workers with infants: 180days ofmaternity leave;breastfeeding breaks of up to one hour per working day until the child’s first birthday; crèche located close to the hospital;human milk bank (HMB), breastfeeding helpline;and trainedlactation consultantsin the neonatal inpatient unit.
The inclusion criteria for participation in the study were as follows: women with non-twin biological children aged between 12 and 36 months born while the mother was employed at the hospital; women breastfeeding after returning to work; absence of an illness (mother and/or child) that could significantly affect BF, such as orofacial malformations or neurological diseases in the infant.
Infant minimum age was set at 12 months because the outcome was defined as BF continuationfor at least 12 months, while maximum age was defined as 36 monthsto minimize recall bias.
In the case of women with more than one child in the stipulated age group, the youngest child was selected.
The data were collectedusing a structured questionnaire prepared by the researchers and administered during pre-scheduledinterviews held at the hospital. Each interview lasted an average of 30 minutes.
Sample size was calculated using an alpha of 5%, power of 80%, prevalence of BFfor at least 12 monthsof 50%9, prevalenceof the main independent variablesof between 50 and 60% (based on a pilot study with seven women), and odds ratio (OR) of 2.0, resulting in a minimum sample of between 296 and 317, depending on the frequencies of the independent variables.
The data were entered twice and checked for mistakes. Statistical analysis was performed using SPSS version 23. Thequantitative variableswere described using means and standard deviations or medians and interquartile ranges, while the categorical variables were presented using absolute and relative frequencies.
Due to the large number of variables used to explain the outcome, we used a hierarchicalregression model10 in which the variableswere grouped into blocks according totheir proximity to the outcome11, forming three hierarchical levels: distal, intermediate and proximate. The levels and respective variablesare shown in Figure 1.
First, we tested the associationbetween the outcomeand the variables in each block using univariate Poisson regression. The variables with a significance level of p<0.20 in the univariate analysis were included in the multivariate analysis in their respective blocks in the Poisson regression (intra-block analysis). The variableswith a significance level of p <0.20 in the intra-block analysis remained in the model until the end of the analysis, adjusting for potential confounding factors.The strength of associationwas determined using crude and adjusted prevalence ratios (PR and PRa, respectively) and their respective 95% confidence intervals (95% CI), adopting a significance level of p<0.05.
The research protocol was approved by the hospital’s research ethics committee andregistered on the Plataforma Brasil. All participants signed an informed consent form.

RESULTS
We contacted 300 women, 49 of whom were excluded because they were notbreastfeeding after their return to work, resulting in a final sample of 251womenwho met the inclusion criteria. Table 1 shows the characteristics of the study population.
Median duration of EBFwas 150 daysand95% of thechildrenwere given milk other than breast milk when the mother returned to work, which occurred between 4 and 11 months (median of 6 months).

Most of the womenreported that they intended to breastfeedfor at least 12 monthsand practically all the sample said that they wanted to continuebreastfeedingafter returning to work;62.3% of thechildren were breastfedfor at least 12 months.

Table 1 shows that most of the womenworked with patient care and only during the day. The average work week was 35.5 hours.

Table 2 shows data related to return to workandbreastfeeding. Approximately three-quarters of the womenreported that they were not informed by the organization about matters relating to breastfeedingafterreturn to work, and level of unfamiliarity with facilities and conditions for workers with infantsvaried according to eachfacility and condition.

Around one-third of the workers expressed breast milkduring workand/or used the HMB. A little under one-quarter of the childrenwent to thecrècheand 13.5% werebreastfedin the crèche. More than half the women said that the place for breastfeeding in the crèchewas inadequate.

Table 3 presents the results of the final hierarchical multivariate model run to determine the association between continuation of breastfeeding for at least 12 months and the study variables.
The following variables showed a positive associationwith breastfeeding continuationfor at least 12 months: mothers without a college degree; mother with previous experience of breastfeeding for at least 12 months; child not givenmilkother than breast milk when the mother returned to work; child had not used a pacifier;and mother works only during the day. The following variables showed a negative associationwith theoutcome: maternal age (3% reduction in prevalence for each year of age); gestational age (7% reduction in prevalence for each week of gestation);mother received breastfeeding support from the child’s caregiver and professional breastfeeding support.

DISCUSSION
This study is the first in Brazil to conduct a detailed investigation of work-related factors influencing BFafterreturn to work and their relation to breastfeeding duration.
Surprisingly, only one of the 22 variableswas associated with BF continuationfor at least 12 months: work shift. Working only during the day increased the prevalence of BF continuationfor at least 12 monthsby37%. This associationwas reported by a previous study in Brazil, suggesting that working night shifts may act as a barrier to breastfeeding due to night-shift fatigue12.
Unlike other studies6,7,13,14, the current study did not find an association between maintenance of BF after return to workandflexible working hours, breaks for breastfeeding or milk expression, appropriate facilities for expressing and storing milk, support from employersand work colleagues,andchild care near or at the workplace. This may be partially explained by differences between our study and the other studies, such as study populationand workplace characteristics, duration of maternity leave, and definition of outcome.
Our findings show that individual and non-work-related factors showed more associations with BF continuationfor at least 12 monthsthan work-related factors. Some of the individual factors associated with maintenance of BF after return to workin the present study – such as maternal age, education level, prior experience of breastfeeding, gestational age, use of milks other than breast milk, breastfeeding support,andusing a pacifier– were associated with duration of BFby previousstudies11,15- 18. Therefore, these factors should also be taken into account when designing strategies for promoting BFafterreturn to work.
The negativeassociationbetween professional support and maintenance of BF for longer found in this study is an apparently paradoxical result. A possible explanation is that the womenwho reported not having received professional support may have had less problems breastfeeding andthus needed less support and were less likely to seek professional help.
Despite the importance of information for breastfeeding management upon return to work17, our findings reveal that the women in our sample were uninformed. Most of the women reported that they had not received guidance from their employer onbreastfeeding upon return to workand were unawarethat they could haveused the services of lactation consultants. In addition, some were unaware that the hospital had a HMBand others didnot even know they were entitled to take one hour off work each day for breastfeeding until the child’s first birthday.
Despite offering various conditions and facilities to promote and protect breastfeeding – for example, being a Baby-Friendly certifiedhospital andthe provision of six months of maternity leave, a HMB, breastfeeding specialists, andchild care near the workplace– the hospital does not develop specific actions directed at womenreturning to work who want tocontinue breastfeeding.This is probably why just one-third of the womenexpressed milk during work, which is essential for maintaining an adequate milk supply. This may also explain why half of the women who expressed milk discarded the milk, despite the hospital providing the necessary facilities for safely expressing and storing milk, thus depriving the child the chance of receiving BM at home in the mother’s absence.
A study conducted in Australia with femalehealth professionals also showed that women were uninformed about aspects related to breastfeedingafterreturn to work19. The findings showed that very few womenspoke to managers aboutbreastfeedingafterreturn to work and were aware of the existence of breaks for breastfeeding or milk expression. More than half of the respondents reported that they would have probably breastfed for longerafterreturn to workif they had received more information and support at the workplace.
In the current study, a little over half of the respondents reported having received support from colleagues and management for continuingbreastfeedingafterreturn to work. Despite this lack of support, the rate in our study was higher than that observed by Weber et al.7 in Australia, where only 11% of respondentsmentioned having received support from management and 13% from colleagues. It is interesting to note that, according to the womenin the present study,there was no difference between the support offered by male and female colleagues.
Studies show that mothers who are unable to breastfeedduring workare more likely to stop breastfeeding early20and that keeping childrenclose to or at the workplace helps promoteBF continuationafterreturn to work by providing the opportunity to directly feed the infant from the breast6.This did not occur with the women in our study, which may be explained by the fact that most of the children that went to the crèche were not breastfed there. The inadequacy of the place for breastfeeding at the crèchereported by the mothers in the present study may have contributed to the low adherence to breastfeedingin this space.
It is interesting to note that, despite not having a specific program for welcoming women returning to work after maternity leave, most of the respondents reported that they were satisfied with the support they received. This may be due to the general level of worker satisfaction with the organization.
It is also interesting to note that duration of EBFwas greater among the womenin the present study than in the general population of Porto Alegre (150 days versus 52 days8). One of the reasons for this difference is that the womenin our study are professionals working in a Baby-Friendly certified hospital.Other factors that may have contributed to this finding include the provision of six-month maternity leave and exclusionof women who weaned their babies before returning to work from the study.
Despite the importance of this study’s findings,it is important to highlight some of its limitations. First, the study was conducted in a single locationwith a population made up predominantly of health professionals. Second, the womenin our study have a number of privileges that most working women in Brazil do not have, including six months of maternity leave, high level of education, and access to a HMBand child care near the workplace. Future research should therefore focus on organizations with different conditions and facilities for breastfeeding womenand different groups of women in order to better understand work-related factors that act as barriers and facilitators for BF continuationafter return to work.
In conclusion, our findings show that work-related factorsthat would usually be expected to negatively influence the maintenance of BF after return to workwere not associated with BF continuationfor at least 12 months. This may be partially explained by the benefits offered by the organization, in particular sixmonths of maternity leave. However, it is probable that a specific program designed to welcome womenwho want to continuebreastfeedingafterreturn to work would increasethe prevalence ofbreastfeeding continuation for at least 12 months and make conciliating breastfeeding and working an easier and more pleasurable experience.The factors associated with BF continuationidentified by this study, including those not directly related to the workplace, should be taken into consideration when designing strategies to promote BFafterreturn to work.
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