clínico da amamentação : Valoração axiológica sob a ótica da mulher-nutriz Clinical management of breastfeeding : axiological value from women ' s perspective

Objective: To analyze the axiological value of nurturing women regarding the clinical management of breastfeeding. Methods: This is a phenomenological qualitative study based on the theory of Max Scheler's values, conducted between May and June 2014 in the joint quarters of two university hospitals in Niterói/RJ and Santa Maria/RS. Twenty nursing mothers participated in the study and The data was organized, subjected to the comprehensive analysis technique and was interpreted according to the value theory and the specific policies of breastfeeding. Results: Two thematic units emerged in the study: breastfeeding clinical management and its vital value and the health network to support breastfeeding care: a utility value. Conclusion: The management of breastfeeding enables a health care that goes beyond the interests, intentions and views of health professionals and institutions; human and existential questions must be seized by rational experiences, linked to those relating to the perception of the nurturer. This perception provides a reframing that is centered in the care provided to women, children and the family.


INTRODUCTION
Public health policies in the fields of children's and women's health related to breastfeeding establish care actions of support, articulated with the primary and hospital care networks, which present important strategies for the initiation and maintenance of breastfeeding 1,2 .In this sense, the National Program to Encourage Breastfeeding (PNIAM), created in 1981 by the Ministry of Health, conjugated multisectoral actions, especially in areas such as health care, legislation, and social communications 3 .However, the indexes achieved still remain far from those recommended by the United Nations Children's Fund (UNICEF) and the World Health Organization (WHO), international organizations that propose exclusive breastfeeding for six months, and complemented until the age of two years or older 2,4 .
There is consensus among the theme of scholars that global rates are stagnating in relation to the breastfeeding practice, emphasizing that, in the last decade, among the 106 million babies born each year, only 50 million (37%) practiced exclusive breastfeeding for six months 1,4 .This finding points to the need to expand the skills to support the management of breastfeeding by nursing and health professionals along with the lactating women, even in the delivery room, not just in the first hour of the baby's life, but continually 4,5 , specially because the breastfeeding routine is configured differently for each woman, making necessary a careful look in terms of the values they engendered in relation to this practice.
However, having a policy for promoting, protecting, and providing support to breastfeeding corroborating the current initiatives aimed at the success of breastfeeding is not sufficient because the nursing mother needs to be immersed in a favorable environment for their life history and their daily lives so that they are able to decide whether they will breastfeed or not.Thus, it is necessary to understand the values of the support offered to breastfeeding, as well as their meanings for those who are involved in this process (nurses and other health professionals).Beside, it needs to enable the expansion of assistance, making it qualified and, above all, individualized 5,6 .This is the relevance of the subject now addressed, which leads to infer that it is essential to have knowledge in terms of the values expressed by nursing mothers, which should be combined with the professional skills to support the management of the various stages of lactation in health services in order to enable each woman to decide for breastfeeding initiation, maintenance and coping with possible problems in her path 7,8 .
It is known that, culturally, women experience the value of breastfeeding support through an emotional sense, since their feelings are related to what seems pleasant or unpleasant.This fact confirms that the value always requires an experience so that the subject is able to acquire knowledge, feeling and thus can recognize and apprehend the values as phenomena related to the perception of an affective state, responding to it positively or negatively.In this case, it causes breastfeeding support to become a value in itself 6 whether expressed by nursing or by other health professionals who work with the nursing mother.Therefore, to contemplate the various aspects involving the theme addressed now the following objective was established: to analyze the axiological value of the woman-nurturer with regard to the clinical management of breastfeeding.

METHODS
This is a qualitative study using a phenomenological approach, based on the Theory of Values 9 aimed at uncovering and, above all, understanding the meaning of the underlying phenomenon to the values of lactating women regarding breastfeeding during the puerperium period.Therefore, one must keep in mind that the phenomenological research is based on the science that is applied to phenomena linked to objects, events and facts and aims at returning to the primary data of lived experience whose purpose is to reveal meanings and create new values 10 .
One aspect that should be considered is that this study did not aim to establish regional differences in the modus operandi of health professionals' study settings since the process of clinical management of breastfeeding occurred in these places with assistance focused on nurturing women, from whom the values of breastfeeding would be seized.
Two federal university hospitals were selected for the study.One of them is located in the city of Niterói, Rio de Janeiro, and the other in Santa Maria, Rio Grande do Sul.
As it is required by Resolution No. 466/2012 of the National Health Council, the study was approved by the Ethics Committee in Research of the Medical School of the Fluminense Federal University under Protocol No. 615,070/2014.The study was conducted between May 1 st and June 30 th , 2014, in the joint quarters of the hospitals.
For the production of data an open interview was carried out using an instrument for the seizure of values regarding the purpose of the study, containing only one guiding question: "Tell me how it was/is for you to receive management/support to breastfeeding in this maternity." The study participants were twenty (20) women admitted to the joint quarters of habitual risk of the aforementioned hospitals; 10 (ten) in each institution, who experienced lactation uneventfully.Women who were in high risk puerperium and women who had not started the phase of lactation were excluded.Those who decided to voluntarily participate in the study and met the established inclusion criteria signed the consent form, which contained detailed information about the research.
The capturing of the answers to the question above was made by means of digital equipment, with the authorization of the participants.The transcripts of the statements obtained during the interviews gave rise to the evaluative senses 9 of the study, which were organized according to the comprehensive analysis technique 11 and were finally interpreted based on the values Theory 2 and the specific public health policies of the breastfeeding area.
It may be mentioned as a study limitation the analysis of the consulted authors which, by virtue of the phenomenological

Breastfeeding clinical management
Alves VH, Padoin SMM, Rodrigues DP, Silva LA, Branco MBLR, Marchiori GRS method, are subjective and, therefore, subject to different views and understandings.Yet, it is expected that the results arouse interest in new research and studies on the subject, generating new knowledge and, above all, the production and dissemination of knowledge.

RESULTS AND DISCUSSION
A brief characterization of the study participants showed that, in terms of age, fourteen were between 20 and 25 years; four were between 26 and 30; one was between 31 and 35; and one was between 36 and 40 years.As to marital status, fourteen were married and six were single.Regarding the number of children, nine had other children, while eleven reported this to be the first.
The evaluative construction of knowledge and practices in the field of breastfeeding presents itself as the everyday values, revealing and instituting rules, routines and patterns in the breastfeeding culture 4,12 .It is understood, from the voice of each nursing mother, in her own way of being, the need for support to the act of feeding her offspring, because the act of breastfeeding was confirmed as a vital value and utility, clearly expressed by the participants of this study.

Breastfeeding clinical management and its vital value
Nursing mothers showed that the process of the clinical management of breastfeeding should value women in their entirety, including their possibilities and limits to experience the act of breastfeeding and allowing the formation of a full bond of trust and meanings with the health professionals who undoubtedly will have beneficial repercussions in the success of breastfeeding.This is because it is considered that the management of breastfeeding is not merely the immanent contemplation of a given object, here represented by the correct technique of suckling; on the contrary, it assumes the desired, causing breastfeeding to transcend the technical and scientific knowledge and reach nursing mothers in the full exercise of a vital value (breastfeeding) 6 .
It is known that everyone seeks the vital values as a process for the very existence.Among them, stand out food, health, environment, and safety.For the newborn and nursing mothers, breastfeeding is a vital value because it is valid for both their lives, as has been said.Thus, the clinical management of breastfeeding saves itself some knowledge experienced in the routine of nursing mothers, whose evaluative expressions comprise a comprehensive care involving the complexity of the act of breast-feeding which means the value vital expressed in the statements of the following respondents: [...] Well, I liked a lot the support to get the knack and breastfeed.He would get angry, wouldn't eat; then the girls showed me how to do it; it worked and he sucked well; he was not hungry; he was quiet and me too [...] (N1).

[...] They help us. (...) If they hadn't help me, I wouldn't know how to breastfeed correctly; maybe the baby wouldn't be gaining weight; I would be trying to nurse her, but she wouldn't be breastfeeding. (...) She got satisfied, not hungry, and she didn't cry anymore [...] (N9).
[...] It helps a lot for nursing.We relax because we know that the baby will be well fed; they provide support; it's important; it makes him develop [...] (N20).
Guidance on how to breastfeed the baby freely is a value understood as an advantage and benefits for the breastfeeding process 13 and health professionals should be able to perceive, from the perspective of women, the values that emerge from this act, such as the nutritional value of human milk or even the sentimental-bond value, which is present in the act of breastfeeding.Nursing mothers have a clear perception of the vital value 2 of breastfeeding, recognizing that the clinical management of breastfeeding gives them a quiet and pleasant practice, in addition to preventing cracks, engorgement and breast mastitis.Moreover, in their speeches unveiling values linked to welfare, nutrition and affection, as well as increased security for breastfeeding on demand, whenever possible.
Importantly, in maternity wards, scenarios of this study, there are acquisitions of values that do not represent only the scientific knowledge 14 .This occurs when a scientific thinking (theory) is encompassed by everyday thinking (of the evaluative practice) 2 .In this case, the daily knowledge includes the structure itself, articulating reason and emotion.It is worth remembering that the acquisitions of individual values are presented in everyday knowledge and, although they are isolated and imbricated on pragmatism of the daily life of lactating women, are become their guides.It follows that the values set in the women's individual field are added to the vital values that engender the unique knowledge of each nursing mother in the experience of breastfeeding, acquired through the support received from health professionals, as reported in the following statements:

[...] Now I know what it is to breastfeed. For me, at least, they [nurses] provided very good attention. In the beginning the nipple began to crack and hurt a lot; everything was done in a way. They helped me, so I relaxed and the baby was fed [...] (N2).
[...] They were nice to me; they explained everything and I understood.Some things I already knew, but they reinforced some things, you know?I was a little afraid; I was thinking that she would not suck and they always encouraged me.Now she is sucking well (..

Breastfeeding clinical management
Alves VH, Padoin SMM, Rodrigues DP, Silva LA, Branco MBLR, Marchiori GRS Several studies 2,[6][7][8] recognize the value given to the clinical management of breastfeeding perceived in the evaluative discourse of the interviewees.However, the value is a timely process that involves a fact at a certain time.Therefore, if this support has its value for the health of the woman and the baby, the vital value emphasized by the mother in her speech presents itself with autonomy, as it has always been and will be worth the pursuit of health as a higher value.However, we must remember that the discourse moves through the reunion in the imagination of the individual's acts (such as consciousness), the source of what determines, in fact, the subject as he/she presents him/herself 15 .Thus, the speeches value the nursing mother of the phenomenon in full enjoyment of the breastfeeding experience as an axiological process in hospitals in living in the puerperal condition, assisted by health professionals who support breastfeeding.
Scholars 6,15,16 also highlight the value of the clinical management of breastfeeding as a facilitator to the practice of women in the breastfeeding process, guaranteeing the possibility of success, which was seized and valued in the statements: [...] I asked for their help (...) the help of the girls in the Milk Bank, to take the stone off my breast, and then they took a look and taught me (...) that when the milk gets hard I have to do a massage and put the baby to suckle, and give her enough breast milk.It has allowed me to relax [...] (N3).

[...] You know? As it was a twin pregnancy, it was a unique experience (laughs), isn't it? (...) Their support for breastfeeding the babies was important. And the technique to breastfeed two was more relaxing with their help [...] (N6). [...] Their support was good to help me not let the baby get hungry and so I wouldn't get nervous; I had doubts about milk production, if it is stimulated, and if the child was sucking. Their support was very good; I felt safer, you know? [...] (N19).
The clinical management of breastfeeding conducted by nursing and by the health professionals is important to overcome difficulties and must occur in prenatal, in the delivery room, in the joint quarters, expanding to the family network, preventing the nursing mother to become susceptible to the myths of weak milk and low milk production, myths that end up favoring the introduction of artificial milk as a way to better nourish the baby.This management enhances self-esteem and confidence in terms of the ability to breastfeed her baby safely 17 , avoiding harmful initiatives toward the newborn.
The recognition of the benefits of breastfeeding, which is an indisputable vital value, is correct; however, each woman is unique in this process, experiencing individual values regarding breastfeeding.Therefore, the support should be singular, as part of the clinical management of breastfeeding.The speeches of the nursing mothers corroborate the scientific literature: the speech has the function of being a truthful representation of reality; only ensuring the permanence of certain representation 15 , here unveiled in the management process as a way for providing support.An advantage of the support was undoubtedly the tranquility to grasp the process of managing breastfeeding in its most diverse aspects, such as the lactation disorders and babies' weight gain.It is clear the perception in terms of the vital value of the support received:

[...] It's good because first my son was hospitalized and spent a week drinking milk in the probe, and I always came and drew the milk right here, and then he suckled my own milk, not the milk of others. My milk is the best, it's life and health and I had their support [...] (N4). [...] They are teaching me well how to do this (...) and that's been nice. (...) For example: to protect my nipple from cracking, I have to help the baby grab strongly, grasp both nipple and (...) [how is it called here?] areola. I didn't know that [...] (N10). [...] They explained that it is not easy to breastfeed, but once you learn it, it is easy. They teach us how to give milk until six months (...) I want to breastfeed. They explained to me right way to do it. They were very gentle to me [...] (N17).
In this sense, the management of breastfeeding establishes values that transcend interests, intentions, views of health professionals and institutional standards, meeting the women who want to breastfeed, regardless of the family network trials, making its most consistent practice with the reality of these women, whose perception evaluates the clinical management of breastfeeding as a concrete possibility of successful suckling.

The health network as a support in breastfeeding care: a utility value
The configuration of the health network involving actions and services of different levels of technology includes technical support in health care construction.This support is perceived as utility value for the sake of successful breastfeeding and should, however, join the network services provided to nursing mothers during hospitalization in the maternity ward and after discharge.Therefore, health professionals involved in supporting breastfeeding may play a decisive role in the onset and breastfeeding maintenance, as long as their actions are integrated by health institutions as support networks 18,19 .
Life "must" produce something useful only to the extent that we can enjoy something pleasant; in this case, when care in breastfeeding is understood as a network that integrates health services, it becomes a utility value 5 .Thus, in the daily routine of this practice there is a useful value, represented here by nursing mothers in terms of the experience of breastfeeding support network as a phenomenon that is revealed in two subjects: on

Breastfeeding clinical management
Alves VH, Padoin SMM, Rodrigues DP, Silva LA, Branco MBLR, Marchiori GRS the nursing mother and the health professional, leaving the latter to recognize the health networks and the real needs experienced by nursing mothers in the breastfeeding process.It is in this sense that underlies the utility value of the support network that seeks and finds deficiencies related to the act of suckling that otherwise would remain hidden.This evaluative perception of the support as an assistance instrument to nursing mothers is explained below: [...] Moving the body hurts; breastfeeding hurts; I could not move.Then she sucked lying down.That was the most difficult part, you know?(...) But they helped.I don't know (...) it is different, isn't it?(...) Sore? (...) I'm leaving today, but things will get better, I'm just worried at home.Where I can ask for help?[...] (E11).
[...]He was born here, so I had support since the beginning in the prenatal and now in the maternity hospital.(...) They've always encouraged me and guided breastfeeding; they helped because it is difficult at first.(...) We don't know, for example, how to put the baby's mouth on breast to suckle it better.(...) I'm just worried because I go home, then, how is it going to be? [..

.] (N16).
The statements reinforce the useful and real value of the need for the healthcare network support for the needs of breastfeeding women.Rede Cegonha (Stork Network) describes the health care network as a service organization of different levels of technological density, which integrates the technical, logistical, and management support systems, ensuring care guided by the comprehensive, humanized, continuous, and quality care 20 .In this sense, nursing mothers reiterate the need for support and expansion of the network to fulfill their needs as they are women experiencing the act of breastfeeding:

[...] Pain, I felt pain and the milk hardened my breast. (...) I went down there [to the Human Milk Bank] and the girl helped me out [the nurse], but I don't I know how it will be at home. [...] (N5).
I considered their support important.I have a lot of milk, but there is the possibility of giving [...]  It is possible to glimpse the possibility of overcoming the dichotomy between support to breastfeeding in the maternity hospital and the healthcare network after hospital discharge, this because nursing mothers evaluate the support network in the subjective/objective dimensions contained in their discourses, which reveal not only the utility value phenomenon, but also its relationship with the desire to breastfeed and overcome possible difficulties from the healthcare network.
It is worth to reaffirm the statements of the interviewees that, while reflecting what everyone knows in terms of the daily life in relation to breastfeeding, may end up silencing what every woman feels and values in her experience by setting the healthcare network fragility in breastfeeding support field 5 exposed the insecurity when dealing with the hospital discharge and the return to their houses, revealing the lack of breastfeeding support networks.This fact deserves consideration by the health professionals of various children's and mother's services to support them in their future demands.
Reinforcing the need for network support for breastfeeding, the Baby-Friendly Hospital Initiative (BFHI) has, as one of its objectives, the promotion, protection, and support to the breastfeeding practices, focusing on the reduction of early weaning and infant mortality and maternal 21,22 .BFHI has guiding principles, such as the Ten Steps to Successful Breastfeeding, and the step number 10 is the one that encourages the formation of support groups for breastfeeding in healthcare networks, where mothers should be immediately forwarded after discharge from the inpatient or outpatient institution; an initiative that sets the useful value of this support network and breastfeeding protection: The useful value, represented here by breastfeeding support, occurs in the evaluative knowledge process, the phenomenological experience that takes place in direct contact between health professionals and nursing mothers; in fact, when the useful value manifests itself in relation to the health needs in the nursing field and are seized in themselves.
The act of evaluating the real necessity of every nursing mother is called mediation 2 .In the evaluative sense, the experiences are present in everyday life as a reaction resulting from emotional concerns of the sensitive nature stimuli; a trend that is satisfied and settles down with the possession of the desired object, in this case, the success of breastfeeding, according to the perception of the interviewees.
Thus, the health network is configured as breastfeeding support and should be the object of attention and commitment of health professionals who work with the nursing mothers in view of the feeding process, which marks the core essence of the useful value of the original intentionality which constitutes the subject (here represented by woman, nursing mothers) in their mode of existence in themselves and with the others (health professionals) in favor of breastfeeding success.

CONCLUSION
The phenomenological approach from the Theory of Values allowed to reveal how the clinical management of breastfeeding occurs in the light of the statements of nursing mothers, considered a process in the field of life (objective and subjective) involving the professional technique and the senses of nursing mothers regarding breastfeeding.
The study showed that the vital and utility values expressed by the interviewees, are perceived by them in daily life, and that management presents health care possibilities that go beyond the interests, intentions and/or views of professionals or of the institution of health.This is because its central nucleus values the human and existential questions which, although shared indiscriminately in various social segments, cannot be grasped only by rational experience.
Thus, this understanding must be linked to those of the evaluative sense of every woman in her role as a nursing mother who is able to reveal her personal values to establish her own marks while breastfeeding, guided in the aspects that value the biological, cultural, and social aspects inherent to the breastfeeding phenomenon.Such aspects were previously unknown by many nursing mothers, whose knowledge emerged from the support received through the management offered by nursing and other health professionals.
Undoubtedly, the theme now addressed has been the subject of interest by many authors, although not under the axiological aspect of nursing mothers in relation to breastfeeding.This aspect sets the unprecedented nature of this article, whose objective is to promote the care aimed at breastfeeding from its clinical management, based on the values established by the women who live this unique experience in their daily lives, and whose evaluative perception brings a reframing of health care centered on woman, child, and the family.
[...] It was good.They explained how I put the baby to suck and not hurt my breast.(...) They said that, when I get discharged and have problems, I must go to a health clinic or come back here.(...) I was nervous, because what would I do at home?And what if my breast got hardened or other difficulties?[...] (N8).
breast milk.(...) So I find it interesting to donate it to those children who are born and are admitted to the NICU.They (the nurses) said that, if I have problems, I could come back here or go to the health post.It's good to know where to go in case breastfeeding doesn't work; they gave me the address of a clinic close to home [...] (N12).[...] I didn't have any of those problems that the girls (other mothers) are having with their breasts.I arrived and was soon forwarded and guided.Everything was all right.So I started to feed him.It was all easy; they (the nurses) are good.Now, at home my mother will help me; let's see how it will be.But it is important to know where to go if something goes wrong.They'll talk about it, I think![...] (N15).
When I had a problem, they tried to help me and were always watching.This makes you feel quiet and safe to breastfeed.(...) The difficulty is hers (the baby) to suck, to pull, to stimulate the nipple, and to stimulate colostrum to leave.The nurses helped me to get know what to do when I go back to work and where to go to seek support.Alves VH, Padoin SMM, Rodrigues DP, Silva LA, Branco MBLR, Marchiori GRS [...] Before I got nervous (...) but I had no problem because until then, since I gave birth to him (the baby), they (the nurses) taught me; they said what I should do and what I should not do.I had no problem, it was good to have them (the nurses) nearby, and they also told me about the breastfeeding room in the health clinic.I will get help if I have problems [...] (N18).