Contradictions in the Breastfeeding Experience: A Clinical-Qualitative Study in Women Who Attended a Breastfeeding Incentive Service

Background: In this study, we explored the mothers perception about their breastfeeding or weaning process. Methods: We conducted a clinical-qualitative study consisting of individual interviews with an intentional sample, closed by theoretical saturation criterion. Results: We analyzed the data using clinical-qualitative content analysis. We interviewed nine mothers aged between 29 and 41 years


Background
Exclusive breastfeeding for the first six months of life is a strategy recommended by the Pan American Health Organization (PAHO) for reducing child mortality PAHO, 2020). Studies have shown that there are advantages to exclusive breastfeeding for six months, when compared with breastfeeding for up to three or four months, followed by mixed breastfeeding. These advantages cover both physiological issues and the construction of affective bonds of the mother-baby binomial (Victora et al., 2016;Karimi et al., 2019;Giugliani, 2018;Quinn, 2018).
However, breastfeeding has been understood to extend beyond a biological and innate act, but also as a social construction (Prado et al., 2016;Lima et al., 2018). In this sense, the reasons for interrupting exclusive breastfeeding before the recommended period, called early weaning, may involve cultural contexts and women's individual experiences (Santos et al., 2018). Therefore, there is a need to understand the women experience and the entire environment that surrounds the breastfeeding process in order to develop interventions that favor the mother-baby binomial.
In Brazil, some social changes have been observed as precursors of early weaning, such as the family and social nucleus in which the woman is inserted, the educational conditions, the labor market insertion, etc. (Lima et al., 2018) However, new social positions for women and labor rights are gradually being conquered, such as the extension of maternity leave to 6 months (Röpke et al., 2020). Such changes already raise reflections on cultural issues that have led women to move further away from the recommendations of international health organizations in relation to exclusive breastfeeding (Section on Breastfeeding, 2012;PAHO, 2020). Breastfeeding is, therefore, a socially, historically, and culturally determined phenomenon, which makes the act of breastfeeding go beyond the simple desire and autonomous decision of women/mothers (Alvarenga et al., 2017).
In addition to the social attributions of women at work, they add to the burdens derived from maternity, showing the complexity of this issue and the importance of its evaluation beyond the recommendations based on biological foundations.
Motherhood not only brings changes and care at the biological level; it brings with it important psychodynamic and social modifications that need to be discussed among health teams (Gianni et al., 2019). Individual psychological factors are more predictive of breastfeeding duration than sociodemographic determinants, confirming that restricting approaches to awareness and information issues is insufficient (Feliciano & Souza, 2011). In this sense, it is necessary for health professionals to understand the psychodynamic aspects involved in breastfeeding or derived from it, in order to better welcome these women. Physical pain during lactation can trigger the risk of developing depressive symptoms in the postnatal period (Gianni et al., 2019) and postpartum depression affects up to 40% of women in developing countries" (Lima & Almeida, 2020). Thus, the exclusive breastfeeding process can become a moment of intense emotional and physical exhaustion, which can lead to its premature interruption (before six months).
In this sense, this study aimed to explore the mother's perception about the process of breastfeeding or weaning, guided by the research question: What is the mother's perception, who were followed-up in a breastfeeding incentive service, about the exclusive breastfeeding or weaning experience? In order to be able to offer support to health professionals for the reception and management of anxieties and challenges, in the search for the qualification of the link between patient and professional in this complex and important phase of life.

Design
This was a qualitative study with a clinical qualitative approach, which investigated and interpreted the symbols that mothers attributed to breastfeeding and/or weaning their children. The human sciences and clinical health tools were used together with understanding of the interpersonal relationships (Campos & Turato, 2009). The theoretical framework used was that of medical psychology. The Ethics Committee of the Piracicaba Dental School-UNICAMP approved this project (CAAE: 15210219.5.0000.5418). Participants were guaranteed anonymity and the option of volunteering.

Setting
The research took place at the Center for research and Dental Care for Special Patients with mothers who, at the time of this research, attended meetings of the GIAME group (Breastfeeding Incentive Group). This Group guided and encouraged mothers interested in breastfeeding their children and enabled them to gain knowledge about some requirements of childcare in their first year of life. The meetings of this group are held under the guidance of a multidisciplinary team, with the participation of dentists, psychologists, nutritionists, speech therapists and nurses.

Sample
Initially, the participants were recruited individually by means of a face-to-face invitation. During the research, the Pandemic caused by the new Coronavirus (COVID -19) led to the imposition of social isolation in Brazil. From then on, the GIAME professionals invited the mothers by phone or e-mail.
According to the inclusion criteria, the study participants were women, mothers, who were attended at a breastfeeding incentive service, and had children aged 0 to 06 months, who are breastfeeding or in the process of weaning. The exclusion criteria was applied to mothers under 18 years of age. The sample was closed, based on the Theoretical Saturation criterion, obtained from the analysis of audio interviews, recorded and transcribed in full, with the language expressions used by the individuals (Batista et al., 2017).

Data Collection
The researcher had previously been working with the group for over a year. This dispensed with the need for a period of acculturation which, however, demanded her to become defamiliarized with the setting (i.e.to stimulate fresh perception of the situation). This took place in a period of 2 months before the research began. with her leaving the group and taking care not to interview the mothers who had previously been guided by her, in order to minimize the possibility of biases. On conclusion of this process, data collection began. In turn, the researcher's experience with this group brought understanding about the psychocultural aspects of population to be studied which contributed to prioritizing the topics to be followed in order to conduct the research and respond to the object of study (Gill, 2020).
After the period of acculturation, individual interviews were conducted using a semi-guided script of open and in-depth questions, in which the researcher considered contextual elements of production of the participants' speeches, in addition to free and open observation (Silva et al., 2015). The script also allowed information to be collected on the social and pregnancy profile (age, education, planning or not for pregnancy and exclusive breastfeeding period). The interviews were held in person (pre-pandemic period of COVID-19) or remotely (during the pandemic of COVID-19). The remote route used was videoconferencing through the Google Meet platform.
The question that triggered the interviews was: "How was it for you to breastfeed?". How did you feel about breastfeeding?" Throughout the interview, topics were discussed: support, bond, concern, relief, work. These interviews were audio recorded and transcribed in full. The average time per interview was 45 minutes. Face-to-face interviews were held in a private room, where the mother (interviewee), the baby (in cases where the baby came to the interview with her), the interviewer and a note-taker were present, in an environment that guaranteed privacy. In remote interviews, the mother was recommended to be alone (so that her privacy was preserved), on a day and at a time that were convenient for the participant.
Data collection took place only after signing the term of free and informed consent, in person and after digitally accepting the term of consent form made available in Google Forms.

Data Analysis
The researched data were treated by means of Clinical-Qualitative Content Analysis (Faria-Schützer et al., 2021). The strategy used for this analysis ( Figure 1) involved a process of organization consisting of seven steps: (1) material and editing -all interviews transcribed; (2) first reading -the researcher undertakes a free reading of the life experiences reported; (3) construction of analysis units -researchers identify meanings, select speech fragments and develop initial reflections on each fragment; (4) construction of codes of meaning, -grouping similar units of analysis, thus structuring the first codes of meaning; (5) construction of categories -organization of the material for analysis by all participants with a view to grouping codes of meaning; (6) discussion -a dialog with the literature available; and (7) validation -critical reflection on the processes carried out at each stage.

Results
Nine mothers were interviewed ranged from 29 to 41 years of age and provided exclusive breastfeeding for 2 to 6 months. Of the nine mothers, only three had previous breastfeeding experiences, one reported an unwanted pregnancy and five had a higher education level, which demonstrated that they were people who may have had greater/better access to knowledge. (Table 1). Three thematic categories were established: 1) The weaning paradox: between discomfort and relief from the process; 2) Leaving something behind: the bond with the child or with the work? and 3) Ambiguity of control -care. P1 "Ah, it was complicated [weaning] because there was concern . . . whether she would be able to stay away from the breast".
The reports of the participants (characterized in Table 1) allowed reflection on how the weaning process can bring contradictory feelings because of understanding the importance of the breastfeeding process, while at the same time realizing the need to interrupt the process. The child's adaptation to a new type of food also becomes a reason for anxiety for working mothers before the end of maternity (or parental leave) leave.
P4 "For me it was not a problem, because when he was 50 days old, I went back to work. So for me it was even more reassuring because he wasn't dependent on me".
Thus, the participants reported the relief of being able to direct their lives in a way that was less dependent on the baby. They also considered it important to offer the child other foods so that, among other things, they could go back to work soon. These contradictory emotional elements arising from the same experience made this process an important paradox to be observed by the care teams.
P4 "It's important to [breastfeed], but I don't miss it. I get sad, it's a pity I haven't been breastfeeding until now... . For me it was easy. I breastfed as long as he wanted, and then I just started to complement".
We observed the idea of not missing a process that [the interviewee] considered important, as a symbol of the paradox of this category. These reports highlighted the desire and anguish about weaning, while it brought the feeling of relief because of the end of breastfeeding. However, the contradictory elements felt by mothers went beyond the act of breastfeeding; they also referred to a thought about bonds. In the reports, we observed a dilemma about whether or not to return to work, both in terms of the success of the weaning process and in terms of the need and desire to return to work. The mothers' speech aroused the feeling that something would be abandoned, generating anguish about whatever choice that would be made. This dilemma was related to interposing elements, such as the need to contribute to household expenses and the desire to go back to work. P1 "It seems as if you are leaving the child aside. It seems as if you're not taking care of it correctly. And with breastfeeding it seemed that . . . you knew he felt more . . . comfortable . . .".
In this context, the mother felt that she was the only person responsible for the baby's well-being. As if in her absence the baby couldn't be comfortable. Leaving the child to go to work was understood as neglecting to take care [of it].
P1 "Some mothers don't mind, right?! I feel very sad about breastfeeding her so little. I wanted to give more".
The reports allowed us to observe a probable process of projection in the speech of these mothers, from which they brought the idea that "other mothers didn't mind" about stopping the breastfeeding. In this sense, they were not always consciously making a reference to themselves. Therefore, they perceived, a capacity, in other mothers, to re-frame the bond based on weaning, which they would have liked to develop, but were unable to.

P8 "I tell my husband that I want to wean him [baby], but deep down you get that feeling of "wow, I'm going to lose him". In a way because you will. This is a very strong bond".
This category gave birth to the idea, brought [to light] by the reports, that the act of breastfeeding could be a consequence of a desire to care, but that it is, however, being maintained by a relationship of dependence on control relationship. Therefore, it was perceived that it was natural and expected that the greatest meaning of breastfeeding was to take care of the baby's health in the most effective way, by offering what was best for him. However, in some statements, a different element of health care could be seen control of the relationship was noted, indicating an inclination to maintain the child's dependence on the mother.
P1 "I felt more relieved [that the baby took the bottle well before she went back to work] because I knew she wouldn't be hungry, right... she wouldn't. But then she took it well, I was relieved [voice choked], she also stays with my cousin.
P6 "You know what a mother is like, the little heart gets . . . you're working, but you're thinking about your son over there".
It is important to realize that this control ends up being a deviation of conduct from the very meaning of caring. The threshold perceived in the speeches between one and the other is tenuous, giving us the idea that mothers needed to be heard so that there would be a clearer understanding of the relationship that has been established with the baby. Otherwise, the actions of the health teams could be misinterpreted or ineffective, keeping the mother-child binomial away from the therapeutic follow-up.

Discussion
In this study, we found that there were contradictions in the mothers' feelings about the breastfeeding process. In general, on the one hand, there was discomfort arising from the feeling of being disconnected from the child at weaning, at times this generated a feeling of excessive control together with the idea of caring. On the other hand, there was relief in the process, because it meant a possibility of returning to work and because the mother felt she was capable of thinking about herself. This contradiction of feelings has been reported in studies that showed that in many cases, the reality of breastfeeding did not reflect the expectations that mothers had about the process (Cortés & Díaz, 2019;Morns et al., 2021). In view of idea that breastfeeding is a natural process, these studies bring to light a confrontation between the reality of the mothers' struggle and cultural construction that breastfeeding is a problem-free process (Berlanga et al., 2013;Cortés & Díaz, 2019). In fact, breastfeeding is a strategy that has been established and validated by international health agencies to reduce child morbidity and mortality PAHO, 2020). Therefore, Brazilian public policies aim to encourage this practice. However, the Brazilian sociocultural particularities and the context of women's work pose specific challenges concerning the implementation of pro-breastfeeding policies. In 2015, over 40 million Brazilian women were inserted into the labor market. This meant 42.8% of the employed population in the country, a situation that directly interferes with the practice of exclusive breastfeeding (Instituto Brasileiro de Geografia e Estatística [IBGE], 2016; Rimes et al., 2019). The participants in this study brought to light the contradictory feelings in precisely this sociopolitical context since they wanted to proceed with the breastfeeding process because they understood its importance, while they also wanted to return to work for reasons of need and self-care.
Therefore, we perceived the relief of women in this study in directing their lives in a way that was less dependent on the baby. In an integrative literature review (Silva & Braga, 2019) on aspects that help to build the mother-baby bond, the authors put forward the idea of breastfeeding as a way of strengthening this bond and as a facilitator of children's health. It is important to note that the studies focused on the improved development of the child and did not raise questions about the social consequences for mothers. This tendency to discuss the benefits of breastfeeding for the child with greater emphasis is reflected in the form of maternal anguish about weaning, while it brings a sense of relief about the end of breastfeeding. Evidence of these paradoxes was shown in the speech of the participants in this study.
Analyzing the complexity of breastfeeding, above all, requires understanding the perspective of those who breastfeed; in this case, the woman, who has protected reproductive rights. In this sense, it is necessary to emphasize that it is up to women, who own their bodies, to have the right to bear, give birth and breastfeed (Prado et al., 2016). Thus, it is also necessary for health professionals to grant a privilege to the voice of mothers; and together with them, build strategies to overcome the subjective difficulties that arise from the social and cultural context in which they live. For this purpose, it is necessary to have in-depth knowledge and understanding of the difficulties that go beyond concerns about the child's development. This study revealed the existential difficulties [there women experienced, and knowledge about these] is important in clinical practice, [to enable health professionals] to provide these women with guidance, as was shown by their ambiguous feelings about breastfeeding.
In this sense, the results of this study showed that the mothers did not report weaning as something they desired, corroborating studies that raised early weaning as an object of discussion (Prado et al., 2016;Euzébio et al., 2017). However, it is important to note that BF requires effort, renunciation, full dedication to the child and a degree of physical and emotional exhaustion that can, in certain contexts, be unbearable for some mothers. Here, in addition to the concrete conditions of life, we still have to consider, the mother's emotional conditions and her ability to deal with stress. In these cases, weaning provides relief from suffering and for some mothers, instead of joy, this can mean feelings of guilt. Moreover, to a large extent, this guilt is a consequence of the authoritarian and prescriptive content of the guidelines that the mothers received, which, in general, "summoned"/ [made it mandatory for} them to breastfeed, as if successful breastfeeding were always possible, despite the context. Based on this scenario, which involved the emotional and social issues of mothers about breastfeeding, the specificity of the work context of these women emerged. The results of this study explored the reports of anguish when the world of work showed up at the same time as the desire [to work] and feeling of abandonment [of the child]. In some studies, it was possible to observe how the mother's socioeconomic level was a decisive factor for interrupting the exclusive breastfeeding. Among financially disadvantaged mothers, breastfeeding goes on for a longer period of time (Lima et al., 2018). The reports of the mothers in the present study illustrated the reality behind these socioeconomic data, corroborating the findings of studies by Lima et al. (2018), noting that mothers had to make the distressing decision between giving up breastfeeding or leaving their professional lives. Those who chose to breastfeed reported the impossibility of working and, therefore, this led to economic difficulties as a factor of anguish. In this decision-making process concerning the conflict between working and caring, it is important to note that for women, work is more than a matter of economic support for the family; it is a source of affective support for the woman herself (Sampaio et al., 2010). As regards this point, the reports in this study observed an ambiguity between the desire to go back to work and the desire to develop a bond with the child. This moment represented suffering for the mothers and their needs to be welcomed by the health professionals who accompanied the women, so that this decision-making process would not bring problems in the development of the caring process of the mother-baby binomial (Sampaio et al., 2010). It is necessary to offer the mother support so that this decision is balanced between the concrete and material needs of the family and the mother's emotional needs. A professional attitude, focused purely on the aim of gaining knowledge can be an obstacle to recognizing the articulation between need-desire-demand (Sampaio et al., 2010).
Therefore, breastfeeding was observed to be an experience of great emotional intensity for the mother and the baby, as the woman came into contact with experiences of fragility together with those of pleasure (Martins, 2018). Winnicot emphasized that if, on the one hand, there was the baby's dependence on the mother, on the other hand, there was the mother's identification with her baby, which allowed her to meet its needs (Winnicott, 2000). Emotional affection between mother and baby is established from pregnancy. As the child's bond with its mother is established, the foundations are formed for the baby's emotional, psychological and social well-being (Marciano & Amaral, 2015). The affective bond, the need for touching between mother and baby is described by Winnicott, who relates the emotional link to the growth, development and reduction in anxiety (Winnicott, 2000). When the mother separates [from the baby], she feels the bond decreasing and, consequently, the anguish increases. The care established by the mother and supported by the family and health professionals are decisive factors for the success of breastfeeding and weaning, as well as for the construction of this bond. However, it is necessary to emphasize that weaning is necessary at a certain point, so that the baby can begin with the progressive acquisition of social bonds. The time for these events to occur, to a large extent, depend on the psychic health of the mother and on the support received during pregnancy and at birth(?) (Kaminagakura, 2016).

Limitations
The face-to-face interviewees were held in the same macro environment in which the mothers participated in a breastfeeding incentive group. To deal with this bias, the interviews were held in a different microenvironment. Remotely conducted interviews restrained the capture of gestures and the unsaid, which may eventually mean loss of psychodynamic aspects.

Conclusion
Women who are breastfeeding or in the process of weaning face many challenges and mixed feelings; they feel relief and discomfort about the process; they feel insecure about the commitment of the bond with the baby. Health professionals can improve these women's experiences by opening a space for listening and understanding not only about the organic issues surrounding breastfeeding, but the emotional and social conditions involved. It is necessary to discuss a breastfeeding support policy that takes into account the contexts of women's work and rights, as well as the responsibilities of health professionals and institutions in providing guidance and care.