Ana C.M. Martins , , Ceres A.V. Oliveira M.B.L. , Elsa Bizon R.J. Giugliani Andrea F. Kroll de Senna , Camila Giugliani , Juliana C.A. Lago ,Agnes breastfeeding for the Brazilian population of a Validation tool to evaluate women’s satisfactionwith ORIGINA

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www.jped.com.br

ORIGINAL ARTICLE

Validation of a tool to evaluate women’s satisfaction with breastfeeding for the Brazilian population ^夽,夽夽

Andrea F. Kroll de Senna

^a^,∗

, Camila Giugliani

^b

, Juliana C.A. Lago

^a

,

Agnes M.B.L. Bizon

^a

, Ana C.M. Martins

^b

, Ceres A.V. Oliveira

^c

, Elsa R.J. Giugliani

^a

aUniversidadeFederaldoRioGrandedoSul(UFRGS),FaculdadedeMedicina,ProgramadePós-Graduac¸ãoemSaúdedaCrianc¸ae doAdolescente,PortoAlegre,RS,Brazil

bUniversidadeFederaldoRioGrandedoSul(UFRGS),FaculdadedeMedicina,ProgramadePós-Graduac¸ãoemEpidemiologia, PortoAlegre,RS,Brazil

cSociedadeBrasileiradeDermatologia(SBD),SãoPaulo,SP,Brazil

Received26January2018;accepted18July2018 Availableonline16October2018

KEYWORDS Questionnaires;

Validationstudies;

Satisfaction;

Breastfeeding;

Maternal Breastfeeding EvaluationScale

Abstract

Objective: To perform the construct validity and the internal consistency of the Maternal BreastfeedingEvaluationScaletool,aimingatitsapplicationintheBrazilianpopulation.

Methods: Cross-sectionalstudythatappliedthetoolto287Brazilianwomen30daysafterchild- birth.Maincomponentanalysiswithvarimaxrotationwasusedforthefactoranalysis,verifying thenumberofsubscalesandthemaintenanceorextractionofthecomponents.Fourhypotheses weretestedusingtheunpairedStudent’st-testforconstructvalidation.Thereliabilityanalysis wasperformedusingCronbach’salphacoefﬁcient.

Results: Theexploratoryfactoranalysisidentifiedtheneedtoexcludeanitemandtorefor- mulatethesubscales.Theresultsoftheconstructvalidityshowedthatallhypothesesproposed wereconfirmed:womenwhowerebreastfeeding,thosewhowereexclusivelybreastfeeding, thosewhodidnothaveproblemsrelatedtobreastfeeding,andthosewhointendedtobreast- feedforatleast12months achievedsignificantlyhighermeanvaluesinthescale.The tool showedadequateinternalconsistency(Cronbach’salpha=0.88,95%CI:0.86---0.90),asdidthe pleasureandfulfillmentofthematernalrolesubscales(0.92,95%CI:0.91---0.93%);childgrowth,

夽 Pleasecitethisarticleas:SennaAF,GiuglianiC,LagoJC,BizonAM,MartinsAC,OliveiraCA,etal.Validationofatooltoevaluate women’ssatisfactionwithmaternalbreastfeedingfortheBrazilianpopulation.JPediatr(RioJ).2020;96:84---91.

夽夽StudyconductedatUniversidadeFederaldoRioGrandedoSul(UFRGS),PortoAlegre,RS,Brazil.

∗Correspondingauthor.

E-mail:andreafks@gmail.com(A.F.Senna).

https://doi.org/10.1016/j.jped.2018.08.008

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development,andsatisfaction(0.70;95%CI:0.65---0.75);andmaternalphysical, social,and emotionalaspects(0.75,95%CI:0.70---0.79).

Conclusions: The validation process of the Brazilian version of the Maternal Breastfeeding Evaluation Scaletoolshowedthatitisvalidandreliabletool tobeappliedtotheBrazilian population.

by-nc-nd/4.0/).

PALAVRAS-CHAVE Questionários;

Estudosdevalidac¸ão;

Satisfac¸ão;

Aleitamento;

EscaladeAvaliac¸ão Maternada Amamentac¸ão

Validaçãodeinstrumentoparaavaliaçãodasatisfaçãodamulhercomaamamentação paraapopulaçãobrasileira

Resumo

Objetivo: Realizar avalidaçãodeconstructoeavaliaraconsistênciainternadoinstrumento MaternalBreastfeedingEvaluationScale,visandoàsuaaplicaçãonapopulaçãobrasileira.

Métodos: Estudotransversal comaplicação doinstrumento a287 mulheres brasileiras após 30diasdonascimentodacriança.Paraaanálisefatorialutilizou-seaanálisedecomponentes principaiscomrotaçãovarimax,verificandoonúmerodesubescalaseamanutençãoouextração doscomponentes.Paraavalidaçãodeconstructoquatrohipótesesforamtestadaspeloteste T-studentnãopareado.Aanálisedeconfiabilidadefoirealizadautilizandoocoeficientedealfa deCronbach.

Resultados: Aanálisefatorialexploratóriaidentificouanecessidadedeexclusãodeumitem e areformulação das subescalas. Os resultados da validade de constructo mostraram que todasashipótesespropostasforamconfirmadas:asmulheresqueestavamamamentando, as queestavamemamamentaçãoexclusiva,asquenãoapresentavamproblemasrelacionadosà amamentaçãoeaquelascomintençãodeamamentarporpelomenos12mesesapresentaram valores médiossignificativamentesuperioresnaescala.Oinstrumentoapresentouconsistên- ciainterna adequada(alfa deCronbach=0,88; IC95%:0,86-0,90),assim como assubescalas prazererealizaçãodopapelmaterno(0,92;IC95%:0,91-0,93),crescimento,desenvolvimento e satisfaçãoinfantil (0,70; IC95%:0,65-0,75)e aspectos físico,social e emocionalmaterno (0,75;IC95%:0,70-0,79).

Conclusões: O processo de validação do instrumento Maternal Breastfeeding Evaluation Scale/BRASILconstatouqueeleéválidoeconfiávelparaseraplicadoàpopulaçãobrasileira.

´

eumartigoOpenAccesssobumalicenc¸aCCBY-NC-ND(http://creativecommons.org/licenses/

by-nc-nd/4.0/).

Introduction

Theimpactofbreastfeeding(BF)onchildhealthiswidely known:protectionagainstrespiratoryinfections,diarrhea, dentalmalocclusion,improvedcognitivedevelopment,and decreased chances of excess weight and diabetes in the future.¹Additionally,itprotectswomenagainstbreastand ovariancancerandtype2diabetes,andincreasestheinter- valbetweendeliveries.^1,2

The World Health Organization recommends exclusive breastfeeding(EBF)intheﬁrst6monthsoflifeandsupple- mentedbreastfeedingupto2yearsormore.³Regardlessof this,theprevalenceofbreastfeedingworldwideandespe- ciallyinBrazilislow.Thelatestnationalsurveyestimated that only 37% of children under6 months are exclusively breastfed,45%between12and15months,and32%between 20and23months.⁴

Inrecentyears,emphasishasbeenplacedonbreastfeed- ing durationas the indicator of success for this practice.

However,formanymothers,breastfeedingsuccessisrelated notonlytoitsduration,butalsotothemutualsatisfaction

ofthemother’sandtheinfant’sneeds,creatingastronger bondbetween them and increasing maternal conﬁdence, withadirectimpactonbreastfeedingduration.^5---8

Thereareveryfewstudiesdedicatedtotheassessmentof thedegreeofwomen’ssatisfactionwithbreastfeedingand littleis known about its determinants. Maternal satisfac- tionwithbreastfeedinghasbeenhigh,withmorethan75%

ofpostpartumwomenbeingsatisﬁedatdifferentmoments during breastfeeding and in different countries.^7,9,10 In recentstudies, early skin-to-skin contact,incentiveto on demandfeedinginthematernity hospital,¹¹ breastfeeding problems,⁶ expectedandeffectively practicedduration,¹⁰ andmaternalself-esteem⁷havebeenassociatedwithsatis- faction.

Currently,to thebest of theauthors’ knowledge, only onetoolisavailableintheliteraturetoassessthematernal perceptionof breastfeeding success,the MaternalBreast- feedingEvaluationScale(MBFES),proposedbyLeff,Jefferis andGagne,in1994.⁵ThetoolwaspublishedinEnglishand validatedin the USA,^5,12,13 also beingusedin Canada,^14,15 Australia,^6,8,16 and Scotland.¹⁷ It has been translated and

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validatedinJapan,^18,19Portugal,^7,20,21andSpain.²²Todate, thereisnorecordofvalidationofthistoolfortheBrazilian population,limitingitsuseinBrazil.²³Basedontheassump- tionthatthewomen’ssatisfactionwithbreastfeedingisvery importantforitssuccess,althoughlittlestudied,thisstudy aimstoperformtheconstructvalidationandevaluatethe internalconsistencyofthetool,aimingatitsapplicationin theBrazilianpopulation,thusallowingstudiestobecarried outthat willidentifythe levelof satisfactionof Brazilian women,aswellasitsdeterminants.

Methods

A cross-sectional study wascarried out withwomen who deliveredtheir children in maternity hospitals located in PortoAlegre,Brazil,fromJanuarytoAugust2016.Oneofthe institutions,HospitaldeClínicasdePortoAlegre(HCPA),isa schoolhospitalthatattends,almostinitsentirely,usersof theBrazilianUniﬁedHealthSystem(SUS).Theotherinstitu- tion,HospitalMoinhosdeVento(HMV),isaprivatehospital.

Theyarebothreferralhospitalsfortypical-riskandhigh-risk pregnancies.

Asimplerandomsample wasselected inthematernity hospitals,includingwomenwhohadasingleton-pregnancy, livebirthnewbornwith≥37weeksofgestationalage,living inPortoAlegre,andwhohadstartedbreastfeeding.Daily, one postpartum woman in the private maternity hospital andtwointhe publiconewererandomly selectedamong theeligibleones,approximately24hafterchildbirth.Aﬁrst contactwasmade atthematernity hospitaltoobtainthe mother’sinformedconsentandtoscheduleanappointment afterthe child completed 30 days of life at her home or anotherplaceofpreference.Somedatawereobtainedfrom themedicalrecords.

Two mother-infant pairs with severe obstetric and/or neonatalcomplicationsthatresultedindeathorhospitaliza- tionintheIntensiveTherapyUnitwereexcluded,aswellas thosewithhealthproblemsthatsigniﬁcantlyinterferedwith breastfeeding,suchasmetabolicdiseasesormalformations.

Thetoolwasself-administeredbythewomenduringvis- itscarriedoutbytrainedinterviewers,between31and37 daysafterdelivery,togetherwithaquestionnairecontain- ing sociodemographic, gestational, postpartum, and child feedingquestionsintheﬁrst30days.

The sample size calculation for the validation process followedthe recommendationthat stipulatesthe need of sevenindividualsforeachquestiontobevalidated.²⁴Thus, aminimumsampleof210womenwasestimated.

OriginalMBFESversion

TheMBFESisaself-administeredtooldevelopedtomeasure thewoman’sself-perceptionregardinghersatisfactionwith breastfeeding.Thisscaleincludesitemsonpositiveandneg- ative experiences andemotions related tobreastfeeding, andconsists of 30self-reported Likert-type items ranging from‘‘stronglydisagree’’ (1point)to‘‘stronglyagree’’(5 points).Amongtheitems,19arepositiveafﬁrmationsscored asmentioned;and11arenegativeafﬁrmations,withinverse scores(items3,5,8,13,14,15,19,22,27,28,and29).It hasthreedimensions:childsatisfactionandgrowth(3,4,7,

10,15,19,24,and28);maternallifestyleandbodyimage (5,8,13,14,22,26,27,and29);andpleasureandfulﬁll- mentofthematernalrole(1,2,6,9,11,12,16,17,18,20, 21,23,25,and30).^5,12Thetotalscorerangesfrom30to150 points,wherehigherscoresindicatepositiveevaluationof thebreastfeeding experience,expressing greatersatisfac- tion.TheMBFEShasshowngoodvalidityandreliability.^5,12 Validationprocess

ThevalidationprocessoftheBrazilianversionoftheMBFES wasprecededbytheauthorizationofitsmaincreator,Ellen W.Leff.⁵Forthisprocess,weusedthetranslatedandvali- datedversionforPortugueseinPortugal.^7,20

The next step consisted in applyingthe toolavailable inPortuguesetowomenonemonthafterchildbirth.During theapplication,theresearcherswereavailablefortheclar- iﬁcation of doubts, shouldthey arise, without interfering in the response.The terms ‘‘burden,’’ ‘‘eager,’’ ‘‘high,’’

and‘‘cow,’’showeddoubts.Thewords‘‘heavy,’’‘‘avidly,’’

‘‘fulﬁllment,’’and‘‘milk-producinganimal’’wereusedas synonymsintheexplanations,respectively.

Dataanalysis

Descriptive data analyses that characterized the sample were carried out according to sociodemographic characteristics,²⁵andthoserelatedtochildbirthandbreastfeeding(meanandstandarddeviationforMBFESscores,and absoluteandrelativefrequenciesfor theother variables).

The Kaiser-Meyer-Olkinand Bartlett sphericity tests were performedtoevaluatethesampleadequacyforthefactor analysis.

As part of the validation tests, the exploratory factor analysisoftheitemswasperformed,throughtheanalysisof themain componentswithvarimaxrotation,toverifythe numberofsubscalesandmaintenanceorextractionofthe components. Onlyitems withvalues>0.4remainedin the tool.²⁶

Theconstructvalidationinformswhetherthetoolscores agree with other measures consistent with the theoreti- cal hypotheses known for the topic of interest.^24,27 This validationevaluatedassociationsbetweentheMBFESscore andthepatternofbreastfeeding,weaning,intentregarding durationofbreastfeeding,andproblemsrelatedtobreast- feeding inthefirst month.Forthispurpose, the unpaired Student’s t-test wasused for fourhypotheses:(1) women whowereexclusivelybreastfeedinginthefirstmonthwould have higher scores in MBFES than women who were par- tiallybreastfeeding;(2)womenwhowerebreastfeedingin thefirstmonthwouldhavehigherscoresthanwomenwho werenotbreastfeeding;(3)womenintendingtobreastfeed longer (>12 months)would have higher scores than those whointendedtobreastfeedforlesstime(<12months);(4) womenwhodidnothaveproblemsduringbreastfeedingin thefirstmonthwouldhavehigherscoresthanthosewhodid.

To performtheseanalyses, the authors considered the following:EBFwhenthechilddidnotreceiveanyfoodrather thanbreastmilk,includingwater,at30days;mixedBFwhen thechildreceived,inadditiontobreastmilk,anothertype ofmilk;andbreastfeedingproblems whenoneor moreof

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thefollowingconditionsoccurredinthefirstmonth:breast engorgement,crackednipple,mastitis,difficultyingetting thebabytolatch,insufficientmilksupply,andanatomical nippleproblems.

Forthereliabilityanalysis,themeasureofthedegreeto whichtheitemsonthescale(orsubscale)ofatoolarecor- relatedbymeasuringthesameconcept, Cronbach’salpha coefﬁcientwasusedtoverifytheinternalconsistencyofthe tooland the domains.²⁴ Cronbach’salpha valuesbetween 0.70 and 0.95 are considered indicative of positivity for internalconsistency.²⁴

The analyses were performed using the software SPSS (IBMSPSSStatisticsforWindows,version21.0,NY,USA).

Ethicalaspects

This study is in compliance with the standards for studies with human subjects²⁸ and was submitted to analysis bythe ResearchEthicsCommittees ofthe HCPAandHMV, beingapprovedunderreportsNo.1,288,088and1,204,288, respectively,in2015.Theparticipantswereincludedinthe studyaftersigningtheinformedconsent.

Results

Thesample consistedof287womenagedbetween16and 45years,withameanof29±6.6years.Sociodemographic characteristics andthoserelatedtochildbirthandbreast- feedingaredescribedinTable1.TheprevalenceofEBFand BFatthematernityhospitaldischargewas81.9%and98.3%, respectively;andattheendoftheﬁrstmonth, 61.7%and 95.8%,respectively.

ThevalueoftheKaiser-Meyer-Olkinmeasureforsample adequacywas0.91,abovethatsuggestedastheminimum requiredforfactoranalysis(0.60).²⁹TheresultofBartlett’s sphericitytest was²(df.435)=4.047.053; p<0.001,indi- catingthatthefactoranalysiswasappropriate.Thisanalysis showedtheexistenceofsixdomainsthatexplained58.8%of thetoolvariability.Sincethissubdivisionhadnopracticalor clinicalimplications,itwasdecidedtogroupthesubscales bysimilarsubjects,asintheoriginaltool,resultinginthe creationofthreesubscales:pleasureandfulﬁllmentofthe maternalrole;childgrowth,developmentandsatisfaction;

andmaternalphysical,social,andemotionalaspects.

Thenewsubscaleswerequitesimilartotheoriginalones, differing only in questions 15, 16, 25, and 27. Question 15‘‘Whilebreastfeeding,Iworriedaboutmybabygaining enough weight,’’ changedsubscale,probablybecause the expression‘‘worried’’isnotanobjectiveevaluationparam- eter of thebaby’s weightgain, but becauseit represents a maternal feelingof concern regarding thisweight gain, beingmuchmorerelatedtothematernalemotionalaspects;

thus,itwasincludedinthenewsubscaleofmaternalphysi- cal,emotional,andsocialaspectsandnolongerinthechild satisfactionandgrowthsubscale.Items16‘‘Breastfeeding wassoothing when my babywasupset or crying’’ and 25

‘‘Breastfeeding made my baby feelmore secure,’’ which belonged to the subscale pleasure and fulﬁllment of the maternal role in the original version, changed subscale, becomingpartofthechildgrowth,development,andsat- isfactionsubscale,as‘‘soothed mybaby’’and‘‘felt more

Table1 Sociodemographiccharacteristicsofthesample, andthoserelatedtochildbirthandbreastfeeding,PortoAle- gre,RS,Brazil,2016(n=287).

n %

SocioeconomicclassAandB^a 163 57.2 Levelofschooling(uptocomplete

highschool)

163 56.8

Caucasianmother 216 75.3

Livingwithapartner 248 86.4

Birthinapublicmaternityhospital 194 67.6

Multiparous 145 50.5

EBFat30days 177 61.7

BFat30days 275 95.8

Problemswithbreastfeedingduring theﬁrstmonth^b

252 87.8

Intentiontobreastfeedreportedin theﬁrstmonth

287 100

≥12months 192 66.9

<12months 54 18.8

Didnotinform 41 14.3

a Thedeﬁnitionofsocialclasses(A,B1,B2,C1,C2,andDE)was carriedoutusingthescoringsystemusedbytheBrazilianAsso- ciationofResearchCompanies(ABEP)inCritérioBrasil 2015, considering the possession ofluxury items, potablewater at home,streetpavement, andlevelofschoolingoftheheadof thefamily.ClassesAandBrepresentfamilieswiththehighest socioeconomicstatus.²⁵Twoofthewomendidnotreportdata forclassiﬁcation(missingdata).

b Presence of problems during breastfeeding: when the mother/babydyadhasoneormoreofthefollowingproblems inthefirstmonthafterdelivery:breastengorgement,cracked nipple,mastitis,difficultyingettingthebabytolatchon,insufficientmilksupply,oranatomicalnippleproblems.

secure’’ are expressions related to baby satisfaction and nottomaternal pleasureaspects.Question27ofthetool,

‘‘Breastfeedingmademefeellikeacow’’hadafactorload of0.28,belowtheacceptablelevel,andwasexcludedfrom theBrazilianversionofthetool(Table2).ThustheBrazil- ianversionoftheMBFES(SupplementaryTable1)resulted in29 items,withsome of them depictingexplanations of thetermsthatgenerateddoubtsduringtheapplication(5, 7,and17).ThenewvaluesfortheBrazilianversionofthe MBFESareshowninTable3.

Theresultsoftheconstructvalidityanalysisshowedthat the hypotheses were confirmed: mothers whoexclusively breastfedtheirinfants inthefirstmonth,thosewhowere breastfeeding in the first month, those who intended to breastfeedlonger,andthosewhodidnothaveproblemswith breastfeedingshowedhigherscoresintheMBFES(Table4).

Theinternal consistencyoftheMBFESwashigh, witha Cronbach’salphaof0.88(95%CI:0.86---0.90).Thesubscales showedacceptablevalues:0.92(95%CI:0.91---0.93)forthe pleasureandfulﬁllmentofthematernalrolesubscale;0.70 (95% CI:0.65---0.75) for maternal physical, emotional and socialaspects;and0.75(95%CI:0.70---0.79)forchildgrowth, development,andsatisfaction.

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Table2 Newdomainsandfactorial analysisvaluespermajorcomponentswithvarimaxrotationoftheBrazilian Maternal BreastfeedingEvaluationScale.

Item Pleasureandfulﬁllment ofthematernalrole

Child’sgrowth,development andsatisfaction

Maternalphysical,emotional andsocialaspects

Subscale1 Subscale2 Subscale3 Subscale4 Subscale5 Subscale6

1 0.74

2 0.79

3 0.68

4 0.60

5 0.67

6 0.76

7 0.61

8 0.58

9 0.65

10 0.50

11 0.51

12 0.79

13 0.52

14 0.66

15 0.69

16 0.43

17 0.55

18 0.75

19 0.57

20 0.73

21 0.80

22 0.71

23 0.64

24 0.62

25 0.55

26 0.45

27 (0.28)

28 0.62

29 0.48

30 0.83

Table3 CharacteristicsoftheBrazilianMaternalBreastfeedingEvaluationScale.

Numberofitems Scorevariation Mean(SD) Median

TotalscoreMBFES/BRASIL 29 29---145 120.92±13.98 124

Subscale:Pleasureandfulﬁllmentofthematernalrole 12 12---60 53.36±6.96 56 Subscale:Maternalphysical,emotionalandsocialaspects 8 8---40 28.21±5.77 29 Subscale:Child’sgrowth,developmentandsatisfaction 9 9---45 39.35±4.99 40 SD,standarddeviation.

Discussion

ThepsychometrictestsforMBFESvalidationfortheBrazil- ianpopulation disclosedsimilarsubscales when compared tothe originalones. However,for theBrazilian versionof theMBFES,itwasnecessarytoeliminateanitemfromthe validatedscaleinPortugal,resultingin29ofthe30origi- nalitems.Question27,‘‘Breastfeedingmademe feellike acow,’’wasexcludedbecauseofthelowfactorload.This probablyoccurred becauseoffeelingsthatweredifferent fromthose expected by the original tool (negative ones) perceivedbysomeBrazilianwomeninrelationtotheword

‘‘cow.’’Somewomendidnotinterpret itasderogatoryor offensive,assuggestedbytheauthors,⁵butasawordthat qualiﬁed themasgoodproducers of milk.This resultcor- roboratestheneedforvalidationofthetoolwhenapplied in different countries,although thesecountries share the samelanguage,butnotthesameculture.

Anotherchangethatoccurredinthevalidationprocessof theMBFESfortheBrazilianpopulationwasthereallocation ofthreeitems(15,16,and25)inthesubscales.However, thischangedoesnotaffectthetotalscore.

InavalidationstudycarriedoutinJapan,theoriginaltool alsounderwentsomechangesregardingthenumberofitems

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Table4 Resultsofhypothesistestingforconstructvalidity oftheBrazilianMaternalBreastfeedingEvaluationScale.

n(%) Meanscore

(±SD)

p

Hypothesis1^a Breastfeeding at30days

287

Yes 275

(95.8)

121.75

±12.92

0.011

No 12

(4.2)

101.91

±22.57

Hypothesis2^a Breastfeeding patternat30 days

275

Exclusive 177 (64.4)

124.44

±11.50

<0.001

Partial 98

(35.6)

116.90

±13.95

Hypothesis3^a Breastfeeding problems intheﬁrst month

287

No 51

(17.8)

126.88

±9.52

<0.001

Yes 236

(82.2)

119.63

±14.46

Hypothesis4^a Intention regarding breastfeeding duration

287

≥12months 192 (66.9)

125.30

±13.67

0.002

<12months 54 (18.8)

117.29

±16.31

SD,standarddeviation.

a HypothesestestedthroughStudent’st-test.

and in thesubscales, by excluding seven items (3, 5, 13, 15,19,26,and28oftheoriginalversion)andreconﬁguring newcombinationsbetweenthesubscales,andthematernal satisfactionwastheonethat underwentfewerchangesin bothstudies.Thus,theJapaneseresearchersalsoobtained threesubscales:maternalsatisfaction,potentiallynegative aspects,andperceivedbeneﬁtsforthebaby,¹⁸althoughtwo arequitedifferentfromthecurrentstudy.Thelargernum- berofexclusionsintheJapaneseversionprobablyoccurred due to the use of a factor load (>0.5) greater than that

usedinthepresentstudyandbythetoolcreators(>0.4).^5,18 The Portuguese validation study didnot perform a factor analysis.⁷

When creating andvalidating theMBFES in the United States, the researchers found higher internal consistency values in the total scale (˛=0.93 and ˛=0.94) and in the following domains: pleasure and fulﬁllment of the maternalrole(˛=0.93and˛=0.91),childsatisfactionand growth(˛=0.88 and ˛=0.83), and maternal lifestyle and bodyimage (˛=0.80 and ˛=0.84), respectively.^5,12 In the Japanese validationstudy,the internal consistencyof the totalscorewasacceptable(˛=0.91),aswellasinthesub- scales(˛=0.91,˛=0.77and˛=0.84),¹⁸beingslightlyhigher than thosefound in the present study. In the Portuguese study, Galvão (2002)⁷ maintained the original items and Cronbach’salpha values were 0.92 in the total scale and 0.92,0.76,and0.76inthesubscales,similartothevalues fortheBrazilianpopulation(0.88,and0.92,0.75,and0.70).

Moreover,inPortugal,theinternalconsistencyvariationfor thetotalscalewasalsosimilartothatfoundinthepresent study(0.90to0.93inthePortuguesestudyand0.86to0.90 inthepresentstudy).²⁰

Inthesamestudy,theCronbach’salphaofthesubscales variedfrom 0.87 to0.92 (pleasure and fulﬁllment of the maternal role),from 0.76 to0.82 (maternal lifestyleand bodyimage),andfrom0.70to0.76(childsatisfactionand growth),whicharelowervaluesthantheonesobservedin theUS,butsimilartothecurrentone.Ramalhoetal.,alsoin Portugal,foundslightlylowervalues(0.89to0.90,and0.65 to0.75,0.66to0.74,and0.88to0.90)tothoseobservedin otherPortuguesestudiesandinthepresentstudy.^7,20,21

Finally, in the validation of the Spanish MBFES, which maintainedthe30items,Cronbach’salphainthetotalscale was0.92, similar to the other studies.²² It is noteworthy that although the Cronbach’s alpha valuesin the present studyareslightlylowerthanthoseofsomevalidationstudies inothercountries,theyareconsideredadequate,allowing theiruseintheBrazilianpopulation.

An advantage of the current study was the fact that thetoolwasappliedduringhomevisits,resultinginahigh returnrate (100%), differentfrom that observed in other studiesthatsentitthroughthemail,withareturnrateof 72---86%.^5,6,12

In the present study, the woman’s satisfaction with breastfeedingwasevaluatedwhen thechild was1 month old. In the other validation studies, the children were 3---5 months old.^7,12,18,22 However, the study that origi- nated the tool does not mention the child’s age when the tool was applied⁵ and it has been used at different momentsofbreastfeeding,from2weeksto12monthsafter birth, suggesting that the tool can be used at different ages.6,8,13---15,17,21

Theculturalaspectsregardingbreastfeedingarediffer- ent in the two populations, including use of terms and expressions. Similar to what happened in some English- speakingcountries,suchasAustralia,^6,8,16 Canada,^14,15and Scotland,¹⁷cross-culturaladaptationwasnotpreviouslyper- formed,whichmayhavebeenalimitationofthisstudy.

DuringthevalidationprocessofthetoolfortheBrazilian population,asitwasthesamelanguage,itwasdecidedto applythequestionnaireintheversiontranslatedinPortu- galinto thePortuguese language,⁷ withno changes in its

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structure, and clarify any doubts during the application.

Fewtermsraiseddoubts,withexplanationsbeingaddedin parenthesestotheﬁnalversionoftheBrazilianMBFES.Itis importanttoemphasizethatthereisnostandardizationfor cross-culturaladaptation whena toolis usedin thesame languagethat wasappliedinanothercountry.³⁰ Moreover, thetoolwaspreviouslyevaluatedbybreastfeedingexperts, whofeltthattherewasnoneedformodiﬁcation.

According to the recommendation by Terwee et al.,²⁴ givenseven subjects for each item of the tool, the sam- plesizeofthisstudy(287)wassatisfactory.However,other authors,more recently,²⁶ have suggested tensubjects for eachitem,whichwouldrequire300participants.Thisdeficit probablydidnotsignificantlyinfluencetheresultsbecause ofitssmallmagnitude.

Inconclusion,thisstudyveriﬁedthattheBrazilianver- sionofMBFESis avalidandreliable tooltobeappliedto theBrazilianpopulationfortheassessmentofmaternalsat- isfactionwithbreastfeeding.Thevalidationandapplication of this tool will demonstrate the level of satisfaction of Brazilian women withbreastfeeding, thus allowing health professionals to plan interventions that can increase this degree of satisfaction, consequently resulting in a more directapproachwhenpromotingthispractice.Furthermore, theavailabilityofavalidatedtoolfortheBrazilianpopula- tionincreasesthepossibilitiesofstudies,stillinexistent,on thedeterminantsofwomen’ssatisfactionwithbreastfeed- inganditsassociationwithseveraloutcomes,includingthe durationofthispractice.

Funding

This work was funded by CNPq [Universal Notice 448186/2014-4] and CAPES research grants were given tothefollowing authors:Andrea F.K.deSenna, AgnesM.

B.L.Bizon,andAnaC.M.Martins.Thefundingsourcesdid notparticipatein anystage ofthe research,preparation, andpublicationofthearticle.

Conﬂicts of interest

Theauthorsdeclarenoconﬂictsofinterest.

Acknowledgements

TheauthorswouldliketothankMBFES’authorEllenLefffor herauthorizationtovalidatethetoolfortheBrazilianpop- ulation.ToGalvãoandGrac¸aforthePortugueseversion.To allthemothersandbabieswhomadethisstudypossible,to HospitaldasClínicasdePortoAlegreandHospitalMoinhosde Ventofortheirsupportintheachievementofthisresearch, totheothermembersoftheteamthatparticipatedindata collection,andtoCAPESandCNPqfortheirfundingofthis study.

Appendix A. Supplementary data

Supplementary data associated with this article can be found, in the online version, at doi:10.1016/j.jped.

2018.08.008

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