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Enfermería: Cuidados Humanizados

versão impressa ISSN 1688-8375versão On-line ISSN 2393-6606

Enfermería (Montevideo) vol.11 no.2 Montevideo dez. 2022  Epub 01-Dez-2022 

Original articles

Breastfeeding Promotion Practices in the Brazilian Hospital Context: An Integrative Review

Hanna Karoliny Alves Peixoto Sousa1

Luis Fernando Reis Macedo2

Simone Soares Damasceno3

Gleice Adriana Araújo Gonçalves4

Naynne Pryscilla Moreira Melo5

Carlo Gigli Lima Alencar6

1 Universidade Regional do Cariri, Brazil

2 Universidade Regional do Cariri, Brazil,

3 Universidade Regional do Cariri, Brazil

4 Universidade Regional do Cariri, Brazil

5 Universidade Regional do Cariri, Brazil

6 Universidade Regional do Cariri, Brazil



Identify breastfeeding promotion practices in the Brazilian hospital context.


This study is an integrative literature review in which the following databases were used: LILACS, BDENF, MEDLINE and PUBMED. Using the descriptors in Health Sciences: Breast Feeding; Hospital; Health Promotion, which are crossed using the Boolean operator AND.


Fourteen studies were selected in this integrative review, which allowed the identification of the following breastfeeding promotion practices in hospital settings: skin-to-skin contact after birth, type of delivery, nursing care, and pain management during the breastfeeding process. Conclusion: It was observed that this study identified the practice of breastfeeding promotion in the hospital context, described in the results in a systematized way. This practice needs to be changed in hospitals and be correctly implemented.

Keywords: breastfeeding; maternal and child nursing; maternal and child health; health promotion.



Identificar práticas de promoção ao aleitamento materno no contexto hospitalar brasileiro.


O presente estudo trata-se de uma revisão integrativa da literatura na qual foram utilizadas as bases de dados: LILACS, BDENF, MEDLINE e PUBMED. Também foi realizado a partir dos Descritores em Ciências da Saúde: Breast Feeding; Hospital; Health Promotion, os quais foram cruzados utilizando o operador booleano AND.


Foram selecionados nesta revisão integrativa 14 estudos que permitiram a identificação das seguintes práticas de promoção ao aleitamento materno no contexto hospitalar: o contato pele a pele após o nascimento, o tipo do parto, a assistência de enfermagem e o manejo da dor durante o processo da amamentação.


Observou-se que este estudo identificou a prática de promoção ao aleitamento materno no contexto hospitalar, descrito nos resultados de forma sistematizada. Constatamos que há a necessidade de mudanças dessas práticas dentro dos hospitais e que sejam implantadas de maneira correta.

Palavras-chave: aleitamento materno; enfermagem materno-infantil; saúde materno-infantil; promoção da saúde



Identificar las prácticas de promoción de la lactancia materna en el contexto hospitalario brasileño.


Este estudio es una revisión bibliográfica integradora que utiliza las siguientes bases de datos: LILACS, BDENF, MEDLINE y PUBMED. Basado en los descriptores de Ciencias de la Salud: Breast Feeding; Hospital; Health Promotion, que se cruzarán utilizando el operador booleano AND.


En esta revisión integradora se seleccionaron 14 estudios que permitieron identificar las siguientes prácticas de promoción del parto materno en el contexto hospitalario: el contacto de la piel con la piel después del nacimiento, el tipo de parto, la asistencia enfermera y el manejo del dolor durante el proceso de amamantamiento.


Se observó que este estudio identificó la práctica de promoción de la salud materna en el contexto hospitalario, descrita en los resultados de forma sistematizada. Esta práctica hace necesario realizar cambios dentro de los hospitales y se implantan de forma correcta.

Palabras claves: lactancia materna; enfermería materno infantil; salud maternal e infantil; promoción de la salud.


Breastfeeding is the primary food in the nutrition of a child under one year of age, it is where all the necessary nutrients are found and in the right amounts for the body of a neonate, in addition to being compatible with the level of development of the gastrointestinal tract, thus avoiding colds and gastroenteritis. In exclusive breastfeeding, the child receives only breast milk and no other liquid or solid (except for supplementary medicines, mineral supplements, or vitamins), and not only the child benefits but also the mother. 1

In addition, the benefits of breastfeeding for children include: it promotes a decrease in mortality rates, prevents complications and the development of infections, allergic, autoimmune, and chronic diseases, improving neuropsychomotor development. The benefits for mothers: it promotes the reduction of bleeding after childbirth, it can protect against a new unwanted pregnancy, it decreases the risks of some cancers and the development of postpartum depression, in addition to facilitating the emotional bond between mother and child. 2

Exclusive breastfeeding is recommended by the World Health Organization (WHO) and the Ministry of Health (Ministério da Saúde - MS), for a period of six months postpartum and supplemented for up to two years or more. 3

Globally, only four in ten (44%) children are exclusively breastfed for the first 6 months of life. In the Americas, this figure was 38% of children, and only 32% continued to breastfeed until the age of two. In Latin America and the Caribbean in particular, less than half of babies (48%) are breastfed within the first hour of life. These rates need to be increased to reach the target of 50% exclusive breastfeeding in the first six months of life by 2025, one of the global nutrition targets, and 70% by 2030. 4

However, early weaning is the result of a complex interaction of sociocultural factors, such as the industrialization process, the emergence, and dissemination of industrialized milk, the respective adherence of health professionals, the prescription of artificial feeding, and the adoption in maternity hospitals of measures that do not encourage breastfeeding, associated with the lack of management of problems that may arise during breastfeeding. 5

With this, the health professional should seek to analyze and understand the process of breastfeeding in the sociocultural and family context in which it occurs, and the understanding of caring for both the mother/baby pair and their family. 1

This study focuses on the breastfeeding process specifically in the immediate postpartum period, still in a hospital environment. A context with many particularities, which deserve attention to favor the adequate practice of exclusive breastfeeding. The lactating woman may present initial difficulties related to breastfeeding, such as delay in colostrum descent, breast pain during the first moments, and difficulties related to positioning and holding the babies properly, among other issues, which can make the breastfeeding process difficult during the period. post childbirth.

It is expected that this research will contribute to the strengthening of actions for the promotion, protection, and support of breastfeeding in the hospital context by nurses, as it will point out practices carried out in hospital services that are known to favor breastfeeding. Thus, this study aims to: Identify breastfeeding promotion practices in the Brazilian hospital context.


This is an integrative literature review. For the development of this research, the following steps were carried out: 1. identification of the theme and research question; 2. establishment of criteria (inclusion and exclusion); 3. categorization of studies; 4. evaluation of included studies; 5. interpretation of results; and 6. presentation of the review. 6

At this stage, the research problem was defined, and the guiding question was elaborated, namely: “How is breastfeeding promoted in a Brazilian hospital environment?”

To find appropriate answers to the research question and in order to better define the population, context and/or problem situation, variables of interest, and results, the Population, Variables, and Outcomes (PVO) strategy was used to search for articles, described in Table 1.

Table 1: Subject descriptors located in DECS for the components of the research question according to the PVO strategy. Crato, CE, Brazil, 2021 

Source: Own elaboration (2021)

For this study, data were collected from the following databases: Latin American and Caribbean Literature on Health Sciences (Literatura Latino-Americana e do Caribe em Ciências da Saúde - LILACS), Nursing Library (Biblioteca de Enfermagem -BDENF), and Medical Literature Analysis and Retrieval System online (MEDLINE) and PUBMED.

The searches were performed using a combination of controlled descriptors, terms contained in the structured vocabulary Health Sciences Descriptors (DECs). The descriptors were as shown in Table 1: Breastfeeding; Hospital and Health Promotion, these were crossed using the Boolean operator AND. The search took place in October and November 2021.

After the search stage was completed, the sample was obtained from the careful reading of each title and abstracts collected in order to confirm whether they contemplate the guiding question of this research and whether they meet the established inclusion and exclusion criteria, namely, inclusion criteria: articles in Portuguese, English and Spanish whose full texts are available and indexed in the aforementioned databases, from 2011 to 2021. Studies dealing with breastfeeding outside the hospital environment and publications that were not scientific articles were excluded from the research. (Table 2).

After selecting the studies, the data were categorized into: title, authors, year of publication, research objectives, database, as well as clippings of significant fragments for the topic under study. These data came to compose the categorization framework of the studies surveyed, presented in the results.

The data were interpreted, that is, discussed based on the critical evaluation of the included studies. At this stage, the main conclusions and implications of these studies were presented, allowing the identification of gaps and paths for future research related to breastfeeding in the hospital context.


In the general search, four hundred and thirty studies were identified in all the electronic databases used. As a search strategy, crossings were used in each database using the Boolean operator 'AND' to associate the descriptors, as can be seen in (Table 2).

Table 2: Number of studies selected in the databases 

Source: Own elaboration (2021)

After applying the inclusion and exclusion criteria, as shown in the sample flowchart below (Figure 1), two hundred and twenty-five duplicate studies were obtained. The remaining two hundred and five articles were selected in the first screening, of these, one hundred and thirty were excluded in the reading stage in full, due to not being in line with the general objective of this research and not having the potential to answer the guiding question. proposal. The final sample consisted of fourteen scientific productions (Figure 1).

Figure 1: Flowchart of the search for composing the final sample 

Table 3 below describes the characterization of the studies included in this integrative review. The articles were characterized in terms of the database in which they were identified, authors, year, type of study, method, place of study, and area of activity of the first author of the research.

Table 3: Characterization of the articles reviewed: database, authors, year, type of study, method, place and area of expertise of the authors 

Source: Own elaboration (2021)

It was observed that the predominant studies in this integrative review were carried out by nurses. The years that concentrated the largest number of publications were the years 2011, 2014 and 2018.

Table 4 t12 t13 describes the objectives and main results of the studies included in this review.

Table 4: Characterization of the selected studies according to the practices of promoting breastfeeding in the hospital environment 

Source: Own elaboration (2021)


The selected studies, in general, aimed to verify the practice of breastfeeding in different hospital contexts in Brazil. It was found that the study population was mostly mothers, nursing, and social care professionals with ages ranging from 19 to 44 years. 7-9,11,13,14

Most studies have pointed to the benefits associated with breastfeeding, given that early breastfeeding after childbirth helps the uterus return to pre-pregnancy volume faster, minimizing bleeding, preventing maternal anemia, and decreasing the risk of breast and ovarian cancer. 10,11,14,15,18 Il also prevents the incorrect formation of teeth and problems in the baby's speech, and provides better development and growth, in addition to the fact that this milk is a complete food, dispensing with water or other foods until the first six months of the baby's life. 1,8-11,15 These studies also showed that breastfeeding can even be a supporting method in the prevention of diseases such as leukemia, in addition to the fact that can prevent orofacial myofunctional changes in the baby. 10,18

Based on the interpretative analysis of the studies included in this literature review, it was possible to elaborate four thematic categories in response to our research question, namely: “How is breastfeeding promoted in a hospital environment?”.

Promotion of breastfeeding in the hospital environment: skin-to-skin contact at birth

The specific study of skin-to-skin contact after birth aimed at encouraging the practice of breastfeeding immediately after delivery was the target five 1,5,8,12,17 among fourteen studies included in this review.

Encouraging this practice is the fourth among the ten steps to successful breastfeeding proposed by a baby-friendly hospital initiative (Iniciativa do Hospital Amigo da Criança) and is intended to promote skin-to-skin contact between the baby and its mother, immediately after birth, for at least one hour, promoting breastfeeding immediately after birth.

This is a very important practice for the promotion and encouragement of breastfeeding. Souza 8 in his study verified that the fulfillment of the fourth of the ten steps for the Success of Breastfeeding is essential for the initiation and maintenance of prolonged breastfeeding since skin-to-skin contact after birth between mother and child has an effect positive for breastfeeding between one and four months after birth, on the blood glucose level of newborns in the first hours of life and also on the cardiorespiratory stability of late preterm newborns.

This skin-to-skin contact between mother and baby after childbirth is seen as a safe and inexpensive procedure that provides short and long-term benefits for mothers and children, thus justifying its systematic implementation in Baby Friendly Hospitals (Hospitais Amigos da Criança - HAC), as highlighted by the authors Silva et al. 1 that sought to evaluate the factors associated with the practice of breastfeeding in the first hour postpartum, in the obstetric center and rooming-in at a University Hospital accredited with the title of Baby-Friendly Hospital (Hospital Amigo da Criança).

However, adherence to the fourth step of the Baby-Friendly Hospital Initiative continues to be a difficulty in Brazil, especially in the Northeast, where, even with the Baby-Friendly Hospital Initiative installed and consolidated in many hospital services, few babies have the chance of being breastfed in the first hour of life, as observed by Silva et al. 1 in their study, which also verified that nurses and pediatricians are the main responsible for implementing the fourth step of the Baby-Friendly Hospital Initiative in those babies who had this opportunity, thus demonstrating the organization of attributions in the context of the routine of the hospitals, showing that health professionals are the protagonists of care and can promote skin-to-skin contact after childbirth in order to improve the rates achieved in this practice.

The association between adherence to skin-to-skin contact and type of delivery was the subject of the study by Campos et al. 4 who verified several factors that influence the beginning and duration of skin-to-skin contact after birth, with emphasis on the type of delivery, since the study showed that both skin-to-skin contact and the time of permanence of the baby with the mother soon after delivery, are reduced when a cesarean section is performed.

Campos et al. 5 also observed that breastfeeding during the first hour of life is predominantly determined by the maternity hospital in which the delivery takes place, and that individual factors, such as age, parity, and maternal education, do not play a significant role.

In addition to this factor presented by Campos et al. 5 that the hospital has an influence on breastfeeding, Belo et al. 12 point out that the hospital environment has a strong influence on breastfeeding, verifying that breastfeeding in the first hours of life can be impaired as a result of the structural conditions of a hospital.

Promoção do aleitamento materno no ambiente hospitalar: o tipo de parto e os desfechos da amamentação

The relationship between the type of delivery and the promotion of breastfeeding in the hospital environment has been the subject of studies, including four studies in this review 7,9,10,16 pointed to a relationship between these variables.

Margotti and Margotti 16 in their study that aimed to determine the factors related to Exclusive Breastfeeding in babies born in a baby-friendly hospital in the city of Belém, observed that mothers submitted to cesarean sections, when compared to those who had vaginal deliveries, demonstrated a high risk of not breastfeeding early or even interrupting lactation in the first month of the baby's life.

Cesarean section, according to Fragoso et al., 9 is responsible for a high occurrence in late rates of breastfeeding initiation. In the literature, this factor is considered to be a risk factor for breastfeeding in the first hours of birth. The same is recognized as such by the World Health Organization itself when it recommends that in child-friendly hospitals, at least 80 % of mothers with normal delivery and 50 % of those undergoing cesarean delivery should be helped to place the baby in skin-to-skin contact to start lactation.

However, being born in a hospital accredited as a Baby-Friendly Hospital, a hospital that supports breastfeeding in several stages, from admission to the departure of the mother with her child from the maternity ward, continues to be considered a protective factor for increasing the duration of exclusive breastfeeding. 16

Therefore, it was evidenced in this review that the stimulation of normal birth in hospitals is a factor directly related to the promotion of breastfeeding, favoring its initiation and duration of practice. It is understood that the mode of delivery can favor the practice of early skin-to-skin contact, greater independence of the postpartum woman in terms of postpartum movement, aspects that admittedly can benefit the establishment of breastfeeding.

Promotion of breastfeeding in the hospital environment: nursing care

Some studies included in this review pointed to the importance of nursing care in the hospital context as an essential aspect of promoting breastfeeding.

The nurse present in the delivery room was observed as a protective factor for early breastfeeding. The study by Ramos et al. 7 whose objective was to evaluate the factors associated with exclusive breastfeeding among public hospitals in Teresina-Piauí, found that nursing professionals are responsible for ensuring the completion of the fourth step of the Baby-Friendly Hospital Initiative, as these play an important role in the preparation of postpartum women, helping them to start breastfeeding and overcome the adversities that this practice brings.

This nursing intervention, in this first contact with breastfeeding, is very important because this professional acts as a facilitator, which promotes the demystification of beliefs, myths, and taboos surrounding the act of breastfeeding. These professionals are still responsible for humanized care, minimizing discomfort and making the newborn's feeding time a pleasant moment for the mother. In addition, specific assistance, and management of complications inherent to breastfeeding in the hospital environment, especially in hospitals accredited by the Baby-Friendly Hospital Initiative, takes place through the work of nurses. Studies 8,9 associate the increase in the duration of breastfeeding with receiving guidance on breastfeeding.

Guiding actions to promote exclusive breastfeeding necessarily involves promoting quality information, as the lack of knowledge on the part of nursing mothers about the practice of breastfeeding has been identified as one of the main causes of abandoning breastfeeding. 9 The nurse who works in the hospital environment is a promoter of breastfeeding and can favor this practice through the promotion of knowledge.

Among the maternal problems related to breastfeeding in the hospital environment, early weaning was verified, motivated by the lack of maternal knowledge about breastfeeding. In the study by Beck et al. 10 the authors realized that the hospital environment and the language used by health professionals when guiding mothers about breastfeeding is a fundamental part for them to effectively absorb the information received. The nurse, as well as the entire health team, must be able to help the woman, through the use of a language appropriate to the mother's needs and degree of understanding, reinforcing the achievements achieved, so that the mothers feel support and confidence in what is being done. being passed on to them.

The study by Mascarenhas et al. 15 points out that although mothers receive information about the importance of breastfeeding, they are often still unaware of several important factors for the development of the child, which agrees with the results of the aforementioned research.

It was found that according to the study by Porto et al. 18) in view of the advantages of breastfeeding already mentioned in this study, the most remembered by the mothers interviewed (60 %) was that breast milk protects the baby against diseases, this fact may be related to popular knowledge, since mothers without guidance also knew of this advantage.

Thus, educational intervention is a potential factor for encouraging breastfeeding in the hospital. For this, nurses need not only to have knowledge and skills but to be sufficiently sensitized to incorporate them into their practice.

Promotion of breastfeeding in the hospital environment: the prevention and management of pain and discomfort during breastfeeding in the hospital environment

Escarce et al. 11 found that among the difficulties encountered during breastfeeding that end up harming breastfeeding are wounds and/or cracks, nipple trauma, the baby's difficulty in holding the breast, and pain/burning. Similarly, the study by Fragoso et al, 9 also found an important difficulty mentioned by the interviewees with regard to the incorrect grip of the newborn and pain.

Authors such as Escarce et al. 11 point out support and emotional support as a priority action of nurses in the first weeks, especially in helping this practice, due to the new experience lived by the woman and also due to the emergence of problems related to breastfeeding, which can cause the early weaning. Thus, the professional must implement measures capable of strengthening lactation in the first hours of life, correcting situations such as, for example, incorrect latching, prevention of breast engorgement and mastitis, and other more serious complications that may occur during breastfeeding.


This integrative review showed that the promotion of breastfeeding in a hospital context takes place through a set of practices with a proven impact to favor breastfeeding. Skin-to-skin contact immediately after birth, type of delivery, nursing care, and pain management during breastfeeding were identified in the studies as aspects that should be promoted and strengthened, with a view to improving breastfeeding outcomes.

It is noteworthy that being born in a hospital accredited by the Baby-Friendly Hospital Initiative or a hospital that supports breastfeeding is considered a protective factor for increasing the duration of exclusive breastfeeding.

This review synthesized knowledge related to the promotion of breastfeeding in hospitals and can be used in the process of sensitizing professionals about the importance of these actions, as well as their commitment to carry them out in the daily life of health services.


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How to cite: Sousa HKAP, Reis Macedo LF, Damasceno SS, Gonçalves GAA, Melo NPM, Alencar CGL. Breastfeeding Promotion Practices in the Brazilian Hospital Context: An Integrative Review. Enfermería: Cuidados Humanizados. 2022;11(2):e2831. DOI: 10.22235/ech.v11i2.2831

Authors’ participation: a) Conception and design of the work; b) Data acquisition; c) Analysis and interpretation of data; d) Writing of the manuscript; e) Critical review of the manuscript. H. K. A. P. S. has contributed in d; L. F. R. M. in c; S. S. D. in e; G. A. A. G. in e; N. P. M. M. in a; C. G. L. A. in b.

Managing scientific editor: Dr. Natalie Figueredo

Received: February 20, 2022; Accepted: September 26, 2022

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