INTRODUCTION

Breastfeeding is widely recognized as the most appropriate form of infant feeding, as it fully meets the nutritional and immunological needs of the baby in the first months of life ^1,2 . In addition to reducing morbidity and mortality from infectious diseases, breastfeeding contributes to the prevention of chronic diseases such as diabetes, promotes the maintenance of a healthy weight, stimulates cognitive development, and is associated with higher intelligence and better school performance^3-5 .

For the mother, breastfeeding provides protection against breast and ovarian cancer, type 2 diabetes, and cardiovascular disease^4-6. For the mother-baby dyad, the release of oxytocin during breastfeeding strengthens the bond and reduces stress⁷.

Furthermore, breastfeeding generates positive impacts not only for the mother and baby, but also for the family and society, including economic benefits ⁸. Because it is associated with better maternal and child health outcomes, breastfeeding contributes to reducing family expenses on medical care and decreases economic losses related to parents taking time off from work to fulfill their caregiving role^9,10.

Exclusive breastfeeding until six months of age, without the introduction of formula or other foods and liquids, is associated with a lower incidence of hospitalizations due to infectious diseases and other complications resulting from early exposure to such products^11,12. Furthermore, breastfeeding initiated on the first day of life can prevent approximately 16% of neonatal deaths, and if initiated within the first hour of life, this number would increase to 22%¹³. Initiating breastfeeding within the first hour of life should be incorporated into hospital routine as a fundamental strategy to promote exclusive breastfeeding (EBF) until six months and its continuation, in a complementary manner, until two years or more^14,15. This recommendation, supported by national and international organizations¹, reinforces the importance of early contact between mother and baby for the success and maintenance of breastfeeding.

Globally, in 2016, the exclusive breastfeeding rate (EBF) was 40%¹⁶. Globally, only 44% of children are exclusively breastfed during the first six months of life. In the Americas, this proportion is 38%, and only 32% continue to be breastfed until they are two years old. In Latin America and the Caribbean, less than half of newborns (48%) receive breastfeeding in the first hour of life¹⁷. In Brazil in 2021, according to data from the National Infant Nutrition Survey (ENANI), approximately 62.4% of children were breastfed in the first hour of life¹⁸. The prevalences of EBF and continued breastfeeding in the first year of life were 45.8% and 43.6%, respectively¹⁸. Despite the identified improvement, efforts are still needed to reach the 80% EBF target stipulated by¹⁶. Thus, despite identified improvements, global efforts are needed to increase these rates to reach the target of 50% exclusive breastfeeding in the first six months of life by 2025, and 70% by 2030, worldwide¹⁷.

Many factors can influence the breastfeeding process⁸, including access to information on the subject during prenatal care¹⁹ , the intention to breastfeed, and social support²⁰. In this sense, health professionals, through actions to support and promote the breastfeeding process during the prenatal period, can influence the increase in exclusive breastfeeding rates²¹, offering guidance on the benefits of breastfeeding, proper breastfeeding management, and the importance of practices such as on-demand feeding, initiating breastfeeding in the first hour of life, and rooming-in²² .

Furthermore, prenatal education should incorporate topics that address women and families about the impacts of artificial feeding, the use of bottles, nipples and pacifiers, reinforcing the need for public policies and projects that facilitate the dissemination of this information¹¹. In this sense, educational efforts should be created , since the lack of adequate knowledge of pregnant women about breastfeeding can negatively influence breastfeeding^8,23.

On the other hand, knowledge made available at the right time and in the right way brings benefits to breastfeeding, since it demystifies cultural, family, lifestyle and personal belief factors that can directly interfere with a woman’s decision to breastfeed²⁴. Thus, close monitoring and adopting a humanized approach is essential to strengthen mothers’ confidence, helping them to overcome challenges and maintain the practice even in difficult situations²⁵.

Therefore, given the above, the objective of this study is to describe pregnant women’s knowledge about breastfeeding.

METHODS

RESULTS

One hundred and eighteen pregnant women met the inclusion criteria and participated in the study. The majority were between 20 and 34 years old (82.2%; n=97), white (54.2%; n=64), lived with a partner (95.8%; n=113), and were not heads of household (74.6%; n=88). The most common outcome was initiating prenatal care before 14 weeks of gestation (93.2%; n=110), while receiving guidance on breastfeeding during prenatal care was cited by a minority (36.4%; n=43 ). It was observed that the majority of pregnant women did not experience difficulties accessing prenatal care during the COVID-19 pandemic (84.7%; n=100) (Table 1).

Table 2 shows the pregnant women’s knowledge about general aspects related to establishing and maintaining breastfeeding. The most well-known topics were the importance of breastfeeding in milk production (n=111; 94.1%), the recommended age range for exclusive breastfeeding (n=111; 94.1%), and the benefits of breastfeeding for the baby (n=108; 91.5%). Being HIV or HTLV positive as a restriction to breastfeeding (n=59; 51.7%) and that there are habits of the child that can be harmful to sucking (n=63; 53.4%) were the least known aspects by the pregnant women.

Regarding the EOR score, most pregnant women answered 2 to 9 items correctly and fell into the “Guide” category (81.36%; n=96), followed by “Praise” (18.64%; n=22), with 10 or 11 correct answers. No pregnant woman obtained a result related to “Recommend”.

Regarding specific aspects related to the benefits of breastfeeding for the baby, avoiding diarrhea (29.7%), a positive effect on intelligence (42.4%), and avoiding respiratory infection (45.8%) were the ones that pregnant women reported knowing least frequently. In investigating the benefits of breastfeeding for the mother, the least reported were the reduction of type 2 diabetes (23.7%), the reduction of the risk of postpartum anemia (28.8%), and the decrease in the risk of hemorrhage (n=38.1%). Regarding the recommendation on the age range for continued breastfeeding, only 40.7% of mothers reported knowing that it should be 24 months or more.

Regarding the main points for the correct latch of the baby to the breast, only one (the baby should latch onto part of the areola in addition to the nipple) was identified as known by the majority of pregnant women (61.9%). When investigated about habits that are detrimental to sucking, pacifiers (53.4%) were the most well-known, followed by bottles (47.5%) and thumb sucking (32.2%). Regarding breast care, the least known precaution among pregnant women was to avoid using soaps or ointments (38.1%). In case of breastfeeding problems, 55.0% of pregnant women reported seeking help from a milk bank, while the nurse at the Basic Health Unit and the doctor were the most frequently consulted. reported by 30.5% and 38.1% of pregnant women, respectively (Table 3).

DISCUSSION

In this study, it was observed that all pregnant women underwent prenatal care and demonstrated basic knowledge about the importance of breastfeeding, showing a certain level of awareness on the subject. However, it was found that most did not receive specific guidance on breastfeeding during prenatal care, highlighting a gap in the educational approach provided by health services. Among the participants, gaps were also identified in knowledge about fundamental aspects related to the establishment and maintenance of breastfeeding.

These findings deserve attention, especially considering that a large proportion of pregnant women began prenatal care before 14 weeks of gestation, which would represent an opportune moment to offer guidance on breastfeeding. The gestational period is crucial for strengthening the intention to breastfeed, and the knowledge acquired during this phase constitutes an important predictor of the duration of breastfeeding³¹. Thus, the role of health professionals in providing adequate information, advice, and encouragement is essential for the success and continuity of the practice^32-34 .

Analyzing prenatal data, it was observed that most pregnant women began prenatal care before the 14th week, but 63.6% did not receive information about breastfeeding during their care. This finding corroborates the results of a study conducted with postpartum women who received prenatal care through the Unified Health System in the State of Santa Catarina, which found a low prevalence (45.9%) of guidance on proper breastfeeding management³⁵. It is worth noting that the present study was conducted during the COVID-19 pandemic, a time when there were impairments in the quality of health services^36,37.

Thus, even with good indicators of coverage and implementation of prenatal care in Brazil, a major challenge remains ensuring the quality of care provided, including educational activities^38-40. For adequate prenatal care, pregnant women and their families should receive guidance throughout the period in order to direct care during this phase, in the postpartum period and with the newborn, especially on the subject of breastfeeding⁴¹.

Regarding knowledge of aspects related to the establishment and maintenance of breastfeeding, it was found that most pregnant women were aware of two to nine of the 11 topics of interest, highlighting the importance of the baby breastfeeding in milk production, the recommendation on the age range for exclusive breastfeeding, and the benefits of breastfeeding for the baby. Similar results come from previous studies, which showed good knowledge about the appropriate duration of exclusive breastfeeding and the importance of breastfeeding^42-44. However, the total breastfeeding duration up to two years of age is less well known than exclusive breastfeeding up to six months²⁷.

Empirical studies show that pregnant women, postpartum women, and women in general more readily recognize the benefits of breastfeeding for the baby (reduction of infections, better nutrition and development) than the benefits for the mother herself ⁴⁵.

Furthermore, the scientific literature describes multiple preventive effects of breastfeeding on infant health — lower infant mortality, fewer respiratory and gastrointestinal infections, and protection against obesity and some chronic diseases later in life ⁴ .

In addition, meta-analyses and reviews show a reduced risk of breast and ovarian cancer and a lower incidence of type 2 diabetes among women who breastfed for longer, evidence that is usually less present in public knowledge⁴⁶.

Furthermore, recent reviews also reinforce that breastfeeding contributes to the prevention of adverse perinatal outcomes (e.g., lower infant mortality and better health trajectories throughout life), indicating that its preventive effects extend beyond the neonatal period⁴⁷.

From a physiological point of view, lactation explains why these preventive effects depend on effective breastfeeding: the newborn’s sucking stimulates the release of prolactin and oxytocin, essential for milk production and ejection⁴⁸.

In this sense, strengthening knowledge about the maternal benefits and the importance of early contact and effective sucking among health professionals can increase breastfeeding rates and, consequently, expand preventive gains for mothers and children⁴.

Regarding issues less known to pregnant women, the restrictions on breastfeeding due to being HIV or HTLV positive were highlighted, as well as the fact that certain infant habits can be detrimental to sucking. Concerning breastfeeding restrictions for mothers with HIV or HTLV, the importance of prenatal consultations conducted by healthcare professionals for all pregnant women is emphasized, especially the implementation of health education activities for HIV-positive mothers who need information/guidance and care aimed at promoting health and preventing vertical transmission, in addition to ensuring the physiological and psychological well-being of these mothers⁴⁹.

A study conducted with pregnant women at a Family Basic Health Unit in João Pessoa identified that 72.5% of pregnant women did not receive guidance on the use of bottles and pacifiers, indicating flaws in the family’s guidance and education process . Regarding harmful sucking habits, it is important that the family is informed about the benefits of natural breastfeeding in contrast to bottle feeding and/or the use of pacifiers. Natural breastfeeding occurs through specific mandibular movements, involving protrusion and retrusion, which are fundamental for bone and muscle growth and for the prevention of physiological retrognathism. During the use of pacifiers, negative pressure occurs, requiring less mandibular movement, which can result in inadequate sucking patterns, contributing to malocclusions and myofunctional disorders. Therefore, it is important to prolong breastfeeding and discourage the use of pacifiers and bottles to ensure healthy orofacial development . The use of pacifiers, for example, may be associated with low prevalences of exclusive breastfeeding and high rates of early weaning; therefore, the role of health professionals is crucial in guiding and supporting mothers, promoting preventive practices that ensure the correct development of children’s facial structures⁵¹.

Regarding the main points for the correct latch of the baby to the breast, almost all were unknown to most pregnant women. Bitencourt and Soratto⁵² found in their studies that the breast latch is among the main difficulties for first-time mothers in relation to the breastfeeding process, which can generate harmful consequences for the mother and baby such as nipple lesions, difficulty sucking, early weaning and greater fatigue during breastfeeding, causing irritability, hence the importance of resolving this problem, through the strengthening of educational practices by health professionals for pregnant women, in a continuous process of care, always aiming at the success of the breastfeeding process⁵³.

In the context of breast care, the advice to avoid using soaps and ointments was the least known among the participants. One of the most researched substances for treating breastfeeding fissures is lanolin; however, there is no evidence that it is superior to hydration with breast milk itself ⁵⁴. Lanolin combined with beeswax and olive oil has recently shown better results⁵⁵, but stronger scientific evidence is needed .

Finally, nurses and doctors were mentioned in low proportions among pregnant women when asked who they sought help from in case of breastfeeding problems. This data is concerning, given that nurses have the technical and scientific competence to provide information and clarify doubts about breastfeeding, and their participation is important from prenatal care to the postpartum period . ⁵²As for doctors, they are considered important supporters of this process, along with other health professionals and the entire family support network, so that signs of difficulty are quickly identified and resolved, leading to a pleasurable and beneficial breastfeeding experience for both mother and child⁵³. The development of educational actions by health professionals is fundamental for the promotion of health and the encouragement of breastfeeding among pregnant women²².

Limitations of this study include the possibility of memory and self-reporting biases, since the research was self-administered. Another limitation concerns the data collection process, which took place via the internet and influenced the representativeness of the study sample. This process did not allow us to reach all population strata (especially people with lower socioeconomic levels), since not all women have access to the internet, smartphones, and computers. Finally, it is worth noting that the data collection strategy used was due to the COVID-19 pandemic in effect at the time of the study. Despite the limitations, our results are consistent with the literature and can be widely considered for guiding public policies on this topic.

CONCLUSION

It was observed that, in general, the participants presented limited knowledge about the topic, with the “Guide” classification predominating in the EOR score. Most pregnant women demonstrated mastery of basic information, such as the recommended duration of exclusive breastfeeding and the relationship between the baby’s sucking and milk production.

On the other hand, there was less knowledge about fundamental aspects to be addressed during prenatal care, such as situations that may restrict breastfeeding, the management of common difficulties, and sucking habits that are harmful to the child’s health. These results indicate that, although pregnant women have a good sociodemographic profile, there are gaps in their understanding of essential topics related to breastfeeding.

It can be concluded, therefore, that pregnant women’s knowledge about breastfeeding is partial and requires further study on practical and preventive topics. The use of the EOR score proved to be a useful tool for identifying these gaps and directing more assertive educational actions, contributing to the strengthening of breastfeeding from the gestational period onwards.