CHARACTERIZATION OF THE PUERPERAL WOMEN'S KNOWLEDGE ABOUT BREASTFEEDING CARACTERIZAÇÃO DO CONHECIMENTO DAS PUÉRPERAS ACERCA DO ALEITAMENTO MATERNO CARACTERIZACIÓN DEL CONOCIMIENTO DE LAS PUÉRPERAS ACERCA DE LA LACTANCIA MATERNA

Objective: to characterize the knowledge of the puerperal women about breastfeeding. Method: quantitative, cross-sectional study, with 232 puerperal women assisted at a high-complexity hospital. The study udes a questionnaire for the socio-demographic profile and one for prenatal care. Descriptive statistical analysis and chi-square and Fisher's exact test statistical tests were performed, presented in tables. Results: among the studied sample, 84.5% are young adults, 80.2% had companions, and 51.3% had low schooling. 73.3% of the women attended six or more prenatal consultations, however, 51.7% of these did not receive any type of information on breastfeeding. Most of the puerperal women who received prenatal guidance consider it as a benefit that offers immunity for the baby (p = 0.0009). Conclusion: there is a superficial knowledge concerning the practical and beneficial results of breastfeeding for the binomial, and a successful practice of breastfeeding depends on the preparation of the women in the gravid-puerperal cycle. In this way, there should be more researches on this theme, through a deeper approach seeking to also check previous experiences in the current breastfeeding. Descriptors: Breast Feeding; Knowledge; Women's Health; Nursing; Prenatal Care; Health Education. RESUMO Objetivo: caracterizar o conhecimento das puérperas acerca do aleitamento materno. Método: estudo quantitativo, transversal, com 232 puérperas assistidas em um hospital de alta complexidade. Utilizaram-se um questionário para o perfil sócio-demográfico e um para Assistência Pré-Natal. Realizaram-se análise estatística descritiva e os testes estatísticos de Qui-quadrado e exato de Fisher apresentados em tabelas. Resultados: entre a amostra estudada, 84,5% são adultas jovens, 80,2% possuía companheiros, e 51,3% apresentaram baixa escolaridade. 73,3% das mulheres realizaram seis ou mais consultas de pré-natal, todavia 51,7% dessas não receberam nenhum tipo de informação sobre aleitamento. A maioria das puérperas que receberam orientação no pré-natal consideram como benefício à oferta de imunidade para o bebê (p= 0,0009). Conclusão: constatou-se que existe um conhecimento superficial relativo à prática e resultados benéficos do aleitamento para o binômio, e que o sucesso da prática do aleitamento materno depende do preparo das mulheres em seu ciclo-gravídico puerperal. Dessa forma, sugere-se a ampliação das investigações sobre esta temática, mediante uma abordagem mais profunda buscando verificar também experiências anteriores na amamentação atual. Descritores: Aleitamento materno; Conhecimento; Saúde da Mulher; Enfermagem; Assistência Pré-natal; Educação em Saúde. RESUMEN Objetivo: caracterizar el conocimiento de las puérperas acerca de la lactancia materna. Método: cuantitativo, el estudio transversal, con 232 puérperas asistidos en un hospital de alta complejidad. Se utilizó un cuestionario para el perfil sociodemográfico y uno para la atención prenatal. Se realizaron análisis estadísticos descriptivos y las pruebas estadísticas de chi-cuadrado y la prueba exacta de Fisher presentados en tablas. Resultados: en la muestra estudiada, el 84,5% son adultas jóvenes, 80,2% tenían compañero, y el 51,3% tenían baja escolaridad. El 73,3% de las mujeres efectuaron seis o más consultas prenatales, sin embargo, 51,7% de ellas no recibieron ningún tipo de información sobre la lactancia materna. La mayoría de las puérperas que recibieron orientación prenatal consideran como un beneficio que ofrece inmunidad al bebé (p = 0.0009). Conclusión: ay un conocimiento superficial sobre la práctica y los resultados beneficiosos de la lactancia materna para el binomio, y el éxito de la práctica de la lactancia materna depende de la preparación de la mujer en el ciclo gravídico-puerperal. De esta manera, se propone la ampliación de la investigación sobre este tema, a través de un enfoque más profundo tratando de controlar también las experiencias anteriores con la lactancia. Descriptores: Lactancia Materna; Conocimiento; Salud de la Mujer; Enfermería; Atención Prenatal; Educación em Salud. Specialist, Federal University of Pernambuco/UFPE. Recife (PE), Brazil. E-mail: flavianataly19@gmail.com ORCID iD: https://orcid.org/0000-0003-0617-7854; Resident, Federal University of Pernambuco/UFPE. Recife (PE), Brazil. E-mail: fernanda10002009@hotmail.com ORCID iD: https://orcid.org/0000-0002-3584-2481; Resident, Federal University of Pernambuco/UFPE. Recife (PE), Brazil. E-mail: nazzamary@hotmail.com ORCID iD: https://orcid.org/0000-0002-2287-9787; Resident, Federal University of Pernambuco/UFPE. Recife (PE), Brazil. E-mail: sthefanny.wlima@yahoo.com.br ORCID iD: https://orcid.org/0000-0002-6787-4736; Master, Federal University of Pernambuco/UFPE. Recife (PE), Brazil. E-mail: marilia_gabrielle170@hotmail.com ORCID iD: https://orcid.org/0000-0003-1764-9810 ORIGINAL ARTICLE Rocha FNPS, Patrício FB, Passos MNS dos et al. Characterization of the puerperal women's... English/Portuguese J Nurs UFPE online., Recife, 12(9):2386-92, Sept., 2018 2387 ISSN: 1981-8963 https://doi.org/10.5205/1981-8963-v12i9a235911p2386-2392-2018 Breast milk is the most complete food, closest to the mother and to the child, with zero cost, which provides children all nutrients they need for a healthy growth. Thus, importance of exclusive breastfeeding stands out, since it promotes the healthy development of the child, minimizing the number of hospitalizations for gastrointestinal infections, respiratory and nutritional problems, besides preventing future dysfunctions, reducing infant mortality. In the same way, it benefits women’s health, since it prevents breast cancer, helps in weight loss, helps the uterine involution, acts as a contraceptive method, among others. Furthermore, there is greater approximation between mother and the child, materializing the affective bond between them. Even with all the improvements perceived with the adoption of breastfeeding as a priority for mother and child, there are still discrepancies regarding the rates of exclusive breastfeeding until the child’s sixth month of life, and complemented up to two years or older. The II Research of Breastfeeding Prevalence in Brazilian state capitals and the Federal District 3 estimates that breastfeeding has an average length of 54.11 days, with a prevalence of 41% in the capitals of Brazil, far from the recommendations. The World Health Organization also warns that if, until 2025, exclusive breastfeeding rates reach up to 50% in the countries of the world, it would prevent 823,000 infant deaths per year. Some studies show that early weaning is influenced by the level of education, culture, emotional state of the mother and knowledge about breastfeeding, and also due to the lack of guidelines and support offered by health professionals regarding complications during prenatal and postpartum. They also mention that the return to labor activities influences the interruption of breastfeeding. Moreover, in Brazil, there is low adherence to breastfeeding, although many campaigns reinforce its importance, reinforcing the idea that the target population is being little prepared to achieve this goal. Thus, providing information on breastfeeding is the main means to resolve the remaining causes of interruption of the act of breastfeeding and bring all the benefits from this action. According to the Ministry of Health, the prenatal consultation is the most appropriate occasion to realize pregnant women’s fears, difficulties and also the desire to breastfeed. This consultation allows addressing questions about the preparation for breastfeeding, possible doubts and encourages the practice of effective breastfeeding, highlighting the right moment to introduce complementary healthy food. It involves the assistance quality not only in basic care, but also at hospital centers. Most women who go through the parturition process, sometime in this period, present difficulties feeding their children, which is justified by the absence of preparation in prenatal consultations, which, besides aiming at following-up pregnancy of these women, is responsible for preparing them at the moment of birth and for their child’s arrival. In addition, many studies discusses the importance of breastfeeding, leaving aside issues related to assessment or verification of knowledge of pregnant women about the theme, since it may influence in the early weaning and consequent reduction in the rates of breastfeeding. Access to information minimizes many problems arising from the lack of breastfeeding, improving the scenario of public health in the country, in addition to facilitating professionals’ work.  To characterize the knowledge of the puerperal women about breastfeeding. This was a cross-sectional, descriptive, quantitative study, carried out at a highcomplexity maternity hospital in the city of Recife-PE. The sample consisted of 232 puerperal women, obtained by means of sample calculation, using the formula for finite population, Standard P= 0.05, with a proportion of 20%. The research included puerperal women who attended prenatal consultations, hospitalized in the joint accommodation of the maternity hospital and that showed health conditions that allowed providing the information requested. The questionnaires were applied by means of face-to-face interviews, based on the degree of knowledge of the puerperal women for breastfeeding practices and guidelines offered in prenatal consultations. Furthermore, questions referring to demographic and socioeconomic characteristics (age in years, race/ethnicity, marital status, education, individual monthly income and religion) were also applied. Data collection occurred in two stages: the first one, in July 2017, performing the pilot test for possible adaptation of the questionnaire according to the local reality. The second step occurred from September to December 2017, in the joint accommodation OBJECTIVE

Breast milk is the most complete food, closest to the mother and to the child, with zero cost, which provides children all nutrients they need for a healthy growth. 1 Thus, importance of exclusive breastfeeding stands out, since it promotes the healthy development of the child, minimizing the number of hospitalizations for gastrointestinal infections, respiratory and nutritional problems, besides preventing future dysfunctions, reducing infant mortality. In the same way, it benefits women's health, since it prevents breast cancer, helps in weight loss, helps the uterine involution, acts as a contraceptive method, among others. Furthermore, there is greater approximation between mother and the child, materializing the affective bond between them. [1][2] Even with all the improvements perceived with the adoption of breastfeeding as a priority for mother and child, there are still discrepancies regarding the rates of exclusive breastfeeding until the child's sixth month of life, and complemented up to two years or older. The II Research of Breastfeeding Prevalence in Brazilian state capitals and the Federal District 3 estimates that breastfeeding has an average length of 54.11 days, with a prevalence of 41% in the capitals of Brazil, far from the recommendations. The World Health Organization also warns that if, until 2025, exclusive breastfeeding rates reach up to 50% in the countries of the world, it would prevent 823,000 infant deaths per year. 4 Some studies show that early weaning is influenced by the level of education, culture, emotional state of the mother and knowledge about breastfeeding, and also due to the lack of guidelines and support offered by health professionals regarding complications during prenatal and postpartum. They also mention that the return to labor activities influences the interruption of breastfeeding. 2, [5][6][7] Moreover, in Brazil, there is low adherence to breastfeeding, although many campaigns reinforce its importance, reinforcing the idea that the target population is being little prepared to achieve this goal. 8 Thus, providing information on breastfeeding is the main means to resolve the remaining causes of interruption of the act of breastfeeding and bring all the benefits from this action. According to the Ministry of Health 7 , the prenatal consultation is the most appropriate occasion to realize pregnant women's fears, difficulties and also the desire to breastfeed. This consultation allows addressing questions about the preparation for breastfeeding, possible doubts and encourages the practice of effective breastfeeding, highlighting the right moment to introduce complementary healthy food. It involves the assistance quality not only in basic care, but also at hospital centers. 9 Most women who go through the parturition process, sometime in this period, present difficulties feeding their children, which is justified by the absence of preparation in prenatal consultations, which, besides aiming at following-up pregnancy of these women, is responsible for preparing them at the moment of birth and for their child's arrival. In addition, many studies discusses the importance of breastfeeding, leaving aside issues related to assessment or verification of knowledge of pregnant women about the theme, since it may influence in the early weaning and consequent reduction in the rates of breastfeeding. 5 Access to information minimizes many problems arising from the lack of breastfeeding, improving the scenario of public health in the country, in addition to facilitating professionals' work.
 To characterize the knowledge of the puerperal women about breastfeeding. This was a cross-sectional, descriptive, quantitative study, carried out at a highcomplexity maternity hospital in the city of Recife-PE. The sample consisted of 232 puerperal women, obtained by means of sample calculation, using the formula for finite population, Standard P= 0.05, with a proportion of 20%. The research included puerperal women who attended prenatal consultations, hospitalized in the joint accommodation of the maternity hospital and that showed health conditions that allowed providing the information requested.
The questionnaires were applied by means of face-to-face interviews, based on the degree of knowledge of the puerperal women for breastfeeding practices and guidelines offered in prenatal consultations. 9 Furthermore, questions referring to demographic and socioeconomic characteristics (age in years, race/ethnicity, marital status, education, individual monthly income and religion) were also applied.
Data collection occurred in two stages: the first one, in July 2017, performing the pilot test for possible adaptation of the questionnaire according to the local reality. In the description of the proportions, there was an approximation of the binomial distribution, the normal distribution for the confidence interval of 95%. In the comparison of proportions, chi-square test and Fisher's exact test were used. For the purpose of interpretation, the limit of the type I error was up to 5% (p<0.05).
The research was approved by the Human Research Ethics Committee of the Federal University of Pernambuco (CAAE 68023417.5.0000.5208), in accordance with Resolution 466/12 of the Ministry of Health, regarding the development of scientific researches involving human beings. The research was financed entirely by the researchers themselves and comply with the formal requirements contained in the national and international regulatory standards for researches involving human beings.
The sample consists of 232 puerperal women, 84.5% are young adults aged over 20 years, with an average of 28.5 years. Table 1 shows the main characteristics of the sample in relation to sociodemographic data. In the general population, 73.3% of the women attended six or more prenatal consultations. Os the patients, 63.4% attened low-risk prenatal care, when compared to those who attended high-risk follow-up (36.6%), representing the majority.
Although a high-risk maternity hospital, puerperal women who attended low-risk prenatal (63.4%) gave birth in this maternity mainly due to: pregnancy-induced hypertensive disorders (48.6%), premature labor (34%), advanced labor (7.6%), gestational diabetes with recent diagnosis/ disorder of the volume of liquids or fetal distress (5.6%), and by bleedings in the second and third quarter (4.2%).
Regarding the type of delivery, 53.0% of the patients progressed to cesarean delivery, which may have been a factor that interfered with the effectiveness of breastfeeding in the first hour of life: 41.4% of the studied population presented time greater than one hour between birth and the first feeding. Of the others, 32.8% breastfed in less than one hour after delivery and 25.9% did not breastfeed. About 51.7% never breastfed, 30.6% breastfed for six months or more and 17.7% for less than six months.
Regarding the provision of guidelines on breastfeeding during prenatal consultations, 51.7% of the women did not receive any information, 23.7% and 24.6% were oriented only on exclusive breastfeeding and importance of breastfeeding, respectively.
When questioned about the complications of breastfeeding, 73.3% were unaware of the complications derived from breastfeeding, while 26.7% reported that fissures, mastitis, abscesses or breast engorgement could occur. Table 2 shows that most of puerperal women who received prenatal counseling considered its benefit the immunity offered for the baby, significantly evidenced with p = 0.0009.

.554 ** (*) Chi-Square Test (**) Fisher's Exact Test
There was a greater number of women aged between 20 and 30, probably suggesting more maturity and emotional balance to deal with the changes imposed by motherhood, corroborating studies carried out in the northeast, south and southeast regions of Brazil.  There is also a considerable number of nursing mothers who had a partner. The presence of a partner represents a favorable factor to the practice and continuity of exclusive breastfeeding, for the affective and emotional support they offer; thus, single mothers have more difficulties maintaining breastfeeding due to the overload of domestic duties and lack of psychological and social support.  Most of the studied population had low schooling and did not have any type of income. Recent studies show that low schooling and family incomestrongly influence the interruption of breastfeeding, since women with more schooling have more access to information and better understand the importance and benefits of breastfeeding provided during prenatal care, being little influenced by external cultures or experiences. Women with low schooling tend to introduce other foods early in the child's diet and have little adherence to prenatal care.  Most of the women included in this study attended six or more prenatal consultations, as recommended by the Ministry of Health, that is, the implementation of at least six consultations ensuring continuity of maternal and perinatal health follow-up. During prenatal care, women are initially guided about breastfeeding, removing doubts, fears and avoiding complications during the practice of breastfeeding. 7,16 This result converges with a study carried out in Canada, which showed that the adequate onset of prenatal care positively interferes with the practice of breastfeeding. 17 Although the number of cesareans in the Unified Health System fell in 2016 18 , the number of cesarean deliveries exceeded that of normal deliveries in the data obtained in this study, which may have influenced the effectiveness of breastfeeding in the first hour of life. A study carried out in the state of Paraná found that cesarean delivery functions as an obstacle to breastfeeding in the first hour of life. 19 In addition, a survey conducted in Brazil in 2014 on birth and delivery, which interviewed 23,894 women from 191 municipalities capital cities and countryside cities, pointed out that cesarean delivery contributes to the separation between mother and baby and is recognized by the World Health Organization (WHO) as a negative condition for the implementation of breastfeeding at birth. 20 Thus, a systematic review that sought to verify the factors associated with breastfeeding in the first hour of life also showed that cesarean delivery was considered the most consistent risk factor for not breastfeeding in the first hour of life. 21 The data whowed that 51.7% of the puerperae received no guidance during prenatal care. Communication and health education are paramount in the preparation of women, provided that it is carried out by qualified professionals. Educational actions during the gestational and postpartum cycle are necessary, and it is during prenatal care that a woman should be prepared to succeed in breastfeeding. [7][8] Even those who claim to have received counseling have limited knowledge, stating that there is a superficial knowledge regarding the practice and beneficial results of breastfeeding for both.
Regarding the recommended time for offering exclusive breastfeeding, 77.6% were in accordance with what the Ministry of Health and the World Health Organization recommend, similar to the results of a survey carried out with puerperal women in Rio Grande do Sul, which sought to verify maternal knowledge about breastfeeding and food introduction. 1, 4,22 The level of knowledge about breastfeeding was strongly related to the guarantee of immunity. A study carried out in Campina Grande -PB showed that, according to the mothers, breastfeeding is related to immunoprotection and to the child's healthy growth and development. 10 Breastmilk offers a range of benefits, ranging from providing more complete immunity and food to positive impacts on recovery and promotion of maternal health. In addition, it reduces infant and maternal morbidity and mortality rates, showing a better quality of life for a country. 1 According to the United Nations Children's Fund and the World Health Organization, exclusive breastfeeding rates are still much lower than expected in the world. Furthermore, they warn that exclusive breastfeeding during the first six months of the child's life would have a great impact not only on the child's health, but also on reducing mortality among women due to breast and ovarian cancer. 4 Guidelines on breastfeeding are one of the factors responsible for breastfeeding selfefficacy and the desire to put it into practice, as the absence of this orientation results in early weaning due to external experiences and influences. 8,23 Furthermore, the guidance offered by professionals leads to the overcoming of barriers that interfere with breastfeeding, as well as improving maternal and child health outcomes. 24 The study presented some limitations that should be taken into account: it was a crosssectional study, which could not determine cause and effect relationships; the interviews were performed in the joint accomodation, when women were still in the puerperium, which did not allow more time for collections, causing operational difficulties to obtain the sample. Nevertheless, it allows characterizing the knowledge of puerperal women in relation to the studied subject, since it presents intrinsic value for the health of the binomial mother and child.
The study investigated the women's knowledge about breastfeeding and its relationship to sociodemographic factors. In general, the success of the practice of breastfeeding depends on the preparation of the women in the gravid-puerperal cycle, especially during the prenatal period. There is superficial knowledge concerning the practice and beneficial results of breastfeeding for the binomial. Statistically, the guidance held in prenatal interferes in the knowledge of the puerperal women with respect to immunological properties found in breastmilk.
The nurse must create a bond of trust with the mother, allowing clarifying doubts related to breastfeeding, management, prevention of complications and difficulties to reinforce the importance of exclusive breastfeeding during the first six months of life, for the health of the mother and the baby.
This analysis may contribute to fill the gaps in other studies found. Based on the data found in this study, there should be more researches on this theme, through a more thorough approach, also seeking to check the influence of previous experience and the presence of the mothers of these nursing mothers in breastfeeding.