The meaning of the social support network for women in situations of violence and breastfeeding

Objective: to understand the meanings attributed to the social support network of women breastfeeding and in situations of violence by an intimate partner. Method: a qualitative study, carried out with 21 women, through semi-structured interviews and data analyzed by the Method of Interpretation of the Senses in the light of the conceptual framework of Social Support Network. Results: all women suffered violence by the partner in the puerperium and only one of them maintained exclusive breastfeeding until 180 days postpartum. In the analysis, the category entitled “The action of the social support network in the face of breastfeeding in the context of intimate partner violence” emerged, with two subcategories: “Interpersonal support network” and “Institutional support network”. In the interpersonal network, the partner was little mentioned, on the other hand, there was a greater participation of other women. In the institutional network, non-resolution and actions centered on biological character were evident. Conclusions: the search for help in the interpersonal network stood out in comparison to the institutional network, both with regard to the issue of violence and breastfeeding and the actions related to it, mostly ineffective, characterized by counseling and referrals.


Introduction
In almost all countries, 80% of newborns receive breast milk (BM) at birth. However, most of these nations have rates of less than 50% of exclusive breastfeeding (EBF) until the sixth month of life and, even after international and national efforts, the rate remains below that recommended by the World Health Organization (WHO) and United Nations Children's Fund (Unicef) (1)(2) . Until 2006, Brazil had an upward trend in breastfeeding (BF) rates and, since then, has maintained stabilization, although breastfeeding indicators have identified that only 36.6% of children remained in EBF until the sixth month of life, as it corroborates rates in underdeveloped and developing countries (3)(4) . To broaden the understanding of such indicators, the complexity of the breastfeeding phenomenon must be considered, since it goes beyond biological aspects and is related to historical, cultural, psychological and social factors, so that these social determinants can be facilitators for the early weaning (5) .
Thus, it is important to understand that breastfeeding is not under the woman's exclusive responsibility, but also a collective duty (5) . In this sense, the social support network (SSN), made up by a partner, family, civil society, State and public institutions, such as the health sector, has a significant role in the experience of healthy breastfeeding for women (6) , as well as for the maintenance of this practice.
The SSN can be defined as the set of interpersonal and social relationships (7) , which can play both a protective and a risky role for individuals, depending on the context in which these relationships develop (8) .
Consequently, the relationships established in the SSN are associated with the social, cultural, political and religious contexts that are integrated among the generations and, in this sense, directly interfere in the way breastfeeding occurs in the live of women (9) .
That said, the importance of incorporating, in the care practices, the participation of the SSN in breastfeeding situations, in order to identify and satisfy the needs of women, as well as minimize doubts, anxieties and ambiguous ideas generated by social practices (of the family support) and scientific knowledge (health field) in order to establish a pleasant breastfeeding (10) . When analyzed the experiences of women in the act of breastfeeding and their interface with the SSN, in interpersonal and institutional aspects, a question echoes: How is the SSN of women who experience breastfeeding and, concomitantly, the situation of intimate partner violence (IPV) configured?
The proposition of the IPV context is justified by two questions: First, it is evident that the SSN is reduced and fragmented in the context of violence (11) ; nevertheless, it appears that the IPV is related to unfavorable breastfeeding practices, such as a low propensity to start breastfeeding, a lower desire to breastfeed, a low probability of maintaining breastfeeding and a greater chance of weaning early (12) .
Furthermore, this study is justified by the literary gap on the influence of the SSN in these two concomitant conditions, that is, in BF practice in women who experience the IPV. Pioneering study on and breastfeeding self-efficacy shows that the association between both phenomena exposes women to unfavorable conditions to breastfeed and reinforces the importance of training health professionals in order to understand and work with this problem (13) . In Brazil, a single study was dedicated to the theme and observed that the lack of an SSN, associated with an IPV context, can be an obstacle to BF practice (14) . Therefore, this study aimed to understand the meanings attributed to the social support network of women breastfeeding and in situations of violence by an intimate partner.

Method
Qualitative study carried out in a city in the inland of the state of São Paulo. 21 women participated in this study, key informants (15) , which were selected from a cross-sectional study carried out with 315 women who received childbirth assistance in a public maternity hospital at usual risk. The research identified the prevalence of IPV cases before pregnancy and in the pregnancy-puerperal cycle. Thus, the inclusion criteria for women in this study were: Having participated in the transversal project; residing in the research municipality; being primiparous; having started breastfeeding; having experienced IPV in the puerperium; and having at least 180 days postpartum.
At least 180 days postpartum were waited to access the EBF phenomenon (1) .
After the stage of identification and selection of participants, recruitment was carried out by invitation, via telephone, to participate in the study. There were no refusals to participate. The meeting was scheduled, according to the person's availability in relation to the day, time and place. As places to conduct the interview, the Basic Health Unit, a private room at the university and the puerperal woman's residence were made available.
When the interview took place at the residence, two authors of the research traveled to the place, for safety Baraldi NG, Viana AL, Carlos DM, Salim NR, Pimentel DTR, Stefanello J.
reasons. The day before the interview, the first author, responsible for the research, confirmed the appointment by phone. Food, water and toys were made available on the spot for the interview to take place smoothly.
Data collection started in April 2015, ending in October of the same year, and was preceded by a pilot study for adequacy. For the interviews, a digital voice recorder was used. The interview took place only once, with an average duration of 42 minutes, and followed a semi-structured script, composed of the following guiding questions: "I would like you to tell me about the discussions between you and your partner and if you sought any help to face them. If so, how was that help? How was it to breastfeed in the face of these situations of fights and disagreements?" The total number of participants was determined by the aspects present in the statements, which began to be repeated and deepened to understand the meanings attributed to the SSN of the participants (16) .

Given the context of violence, leaflets and booklets
with content on violence against women (VAW) and on the SSN in the municipality were offered to all women.
On the occasion, these women were referred to the psychology service of a public university and, when required, they were also referred to the assistance support service for people in situations of violence or in risky conditions in the municipality.
In the analysis of the data, the interviews were fully transcribed by the first author, without the grammatical correction of their speeches being carried out, in order to maintain the original meaning. The data were analyzed using the method of interpretation of the senses, with the following steps:  and with the empirical data (17) . In this perspective, the conceptual framework used was the Social Support Network (18) .

Initial codes Intermediate codes Final themes: Sub-category
Lack of partner support   were housewives, five worked with a formal contract, two were unemployed, and one worked without a formal contract and another was a student.
Of the 21 participants, nine claimed to have This category was divided into two subcategories, which showed the phenomenon of IPV and BF according to the composition of the network, so they were entitled: "Interpersonal support network" and "Institutional support network".

Discussion
The characteristics of the participants in this research corroborate the literature in the area.
Reflecting on such socioeconomic characteristics is a unique situation, since there is a complex network of risk factors (19) , which can be mediated by internal and private issues of each subject (20) , which makes violence a multifaceted phenomenon.
When turning their attention to the pregnancypuerperal cycle and the perpetuation of IPV, most women declared that they had not suffered violence during pregnancy. In contrast, in the postpartum period, IPV worsened, given the greater association between the types of violence suffered. In view of what was seen, two studies showed contrasting results: one found an incidence of violence in the postpartum period around 9.3% (19) , while the other (21) , even with a drop in violence compared to the gestational period, it was pointed out that 25.6% of the participants reported continuity in the puerperium. In this regard, it is noted that the puerperal woman is also exposed to IPV, regardless of whether the violence starts or continues in the puerperium.
In the practice of breastfeeding, it was evidenced that, at 180 days postpartum, only one woman was in EBF, and nine babies were weaned. These results show that abusive relationships can constitute barriers to the practice of BF, as observed in a study (22) cross-sectional retrospective that analyzed 195,264 records and found that 11,766 women reported suffering some type of IPV during prenatal care, of which 36.3% did not breastfeed their children. Women who started breastfeeding and were in an IPV situation had an 18% increased chance of interrupting BF in the first eight weeks after delivery.
In the first thematic subcategory, it was evident that the partner was not recognized as part of the women's SSN during the puerperium and breastfeeding process, a fact aggravated by the situation of IPV, since the bond was weakened. It is known that social support, when present and shared by the partner, has a positive impact on the woman's esteem, helps with the emotional instabilities that may be present in this phase www.eerp.usp.br/rlae 6 Rev. Latino-Am. Enfermagem 2020;28:e3316. and contributes to the adaptation of the new social role. In addition, being present in the care of the baby reaffirms the affective bond and removes the woman from the position of sole responsible for the care, wellbeing, nutrition and development of the child (23) .
Interpersonal SSN was represented by women, especially mothers in-law, cousins, aunts and friends.
This fact reaffirms that care during motherhood spreads symbolically between generations, especially among women, but the partner can also collaborate in the breastfeeding process (24)(25) , different from the result observed in the present study. In addition, for some participants, the IPV situation accentuated a relational incompatibility with the family members. Therefore, it is noted that the breach of family precepts may come to contribute to SSN fragility (26) . In this regard, these weakened relationships promote a distance between these members and increase the chance of women remaining in situations of social vulnerability (27) .
In terms of functionality, interpersonal SSN was found in actions ranging from advices to helping to shelter women in relatives' homes. However, in some situations, this SSN also indirectly contributed to the woman remaining in a situation of violence, with attitudes rooted in the role of gender and power relations. This result corroborates the literature, since, socially and culturally, socialization still naturalizes differences in behavior according to gender and, thus, puts women as fragile and submissive to men, a fact that can be intensified by relations with the SSN (19,(28)(29) .
Still in this context, women who remained at the side of their aggressors were stigmatized, which directly impacts the attempt to disrupt the network, as it can increase the partner's power over women (30) .
The blaming, on the part of the interpersonal network, accentuated the feelings of shame and failure, as well as isolation for the women in this study, allowing the invisibility of IPV, the non-blaming of the aggressor, the male domination relationship and, therefore, the perpetuation of violent relationship (11,29,31) .
In BF practice, it was found that family members, especially grandmothers, friends and neighbors were present, especially in the initial difficulties with the BF.
The greater the intergenerational bond, the greater the sociocultural influence for the inclusion of food in the baby's diet. This fact contributed to the discontinuity of EBF and, in some situations, added to the context of IPV and contributed to early weaning. In this regard, metasynthesis (9) who assessed the knowledge, attitudes and practices of grandmothers related to the support offered in the practice of BF showed that they are central figures and influence daughters or daughtersin-law to breastfeed, by offering support, at the same time that they can promote the discontinuity of the act breastfeeding through contrary opinions and inadequate information. Therefore, it is necessary to understand that the network, mediated by the interpersonal context, can both promote support, well-being and changes, as well as the disarticulation of the individual and his ongoing internal processes (6) .
In the second subcategory, the institutional SSN corresponded to the services required by women.
However, it was reduced when compared to the interpersonal network, and was configured by little protective actions in the face of the IPV and breastfeeding, without intersectoral action. This finding can be explained by the structuring of institutional networks, which, being secondary networks, are characterized by relationships dominated by law, unlike primary networks (interpersonal), formed by significant relationships, of reciprocity and trust (11) . Thus, if the "micro network" is classified as the family network, the "macro network" is the one that includes the action of the community and society under the individual (6) .
In this study, institutional SSN was composed of the health, public security, judicial and NGO sectors.
In the context of violence, the search for institutions that make up the network is called, in the literature, as a critical route (32) , since non-integrality and transversality culminate in the fragility of services and hinder conflict resolution, thus compromising the quality of care (32)(33) .
Regarding the functionality of the institutional network, fragmented and low-resolution actions were observed, characterized by assistance to women through referrals. These actions, in addition to weakening the integrality of care, perpetuate the cycle of violence, since the woman does not feel welcomed and supported by the services (30,(32)(33) given the understanding that IPV is something to be resolved within the family mainstay.
Thus, attention is hardly configured as a resolving action (29) .
The same fragmented actions were observed in relation to the practice of breastfeeding, through which there was a predominance of assistance without qualified listening and without individualization of care. In order to change this model of care, new perspectives of care must be proposed, in order to facilitate meeting the demands. In the set of these actions, the permanent education of the professionals and the collaborative and interprofessional actions stand out, which provide a care more consistent with the real needs of women (34) .
Something significantly symbolic in this study was the approach of IPV and BF separately and as nonassociated events, a fact that did not allow networks to www.eerp.usp.br/rlae 7 Baraldi NG, Viana AL, Carlos DM, Salim NR, Pimentel DTR, Stefanello J.
provide functionality and meaning for these participants.
In this sense, it appears that it is necessary to give greater visibility to the interface of violence and practices in breastfeeding, in order to ratify the merit of this study, as well as to justify the development of others on the subject at issue.
Nevertheless, in view of the submitted results, the importance of understanding the SSN as a dynamic thing is highlighted, that is, in which both -SSN and the individual -interact, sometimes in order to complement each other, sometimes to repel and, for therefore with the possibility of conflict. Thus, not all SSN can be totally beneficial or harmful, but they are built according to the context in which the subject is inserted, always aiming at the perspective of protection, which is why an individual without SSN tends to be more fragile and isolated (6) .
The greatest advancement of this study for scientific knowledge is linked to the fact that it understands that the IPV significantly interferes in the BF practice.
In addition, it was possible to observe that both interpersonal and institutional SSN were not enough to change the trajectory of breastfeeding in situations of IPV. However, the main limitation of the study is related to the specificities of the participants, which can make it difficult to generalize these results to other contexts.
On the other hand, the data presented here give rise