Social representations about support for breastfeeding in a group of breastfeeding women

Abstracts

Este estudo teve como objetivo conhecer as representações sociais de um grupo de nutrizes sobre o apoio para amamentar e, também, identificar as ações do entorno social que são percebidas por essas mulheres, como apoio em seus processos de amamentação. Os dados foram coletados por meio de abordagem qualitativa, em entrevista semiestruturada gravada, e organizados conforme a proposta do Discurso do Sujeito Coletivo e analisados segundo os pressupostos da Teoria das Representações Sociais. Os resultados mostraram que as representações das mulheres deste estudo, sobre o apoio para amamentar, são constituídas pelas ações disponíveis no contexto hospitalar, familiar e de trabalho. Sob a ótica da mulher, o apoio é um fenômeno de grande amplitude que engloba aspectos do incentivo, da promoção e da proteção à amamentação.

aleitamento materno; apoio social; saúde da mulher

Este estudio tuvo como objetivo conocer las representaciones sociales de un grupo de amamantadoras sobre el apoyo para amamantar y, también, identificar las acciones del entorno social que son percibidas por esas mujeres, como apoyo en sus procesos de amamantar. Los datos fueron recolectados por medio de un abordaje cualitativo, en entrevista semiestructurada grabada, y organizados conforme la propuesta del Discurso del Sujeto Colectivo y analizados según las concepciones de la Teoría de las Representaciones Sociales. Los resultados mostraron que las representaciones de las mujeres de este estudio, sobre el apoyo para amamantar, son constituidas por las acciones disponibles en el contexto hospitalario, familiar y de trabajo. Bajo la óptica de la mujer, el apoyo es un fenómeno de gran amplitud que engloba aspectos de incentivo, de promoción y de protección al amamantamiento.

lactancia materna; apoyo social; salud de la mujer

ARTIGO ORIGINAL

Social representations about support for breastfeeding in a group of breastfeeding women

Fabiana Swain Müller^I; Isilia Aparecida Silva^II

^IEscola de Enfermagem, Universidade de São Paulo, Brasil: RN, Master's student in Nursing, e-mail: [e-mail]

^IIEscola de Enfermagem, Universidade de São Paulo, Brasil: RN, Ph.D. in Nursing, Full Professor, e-mail: [e-mail]

ABSTRACT

This study aimed to get to know the social representations about support for breastfeeding in a group of breastfeeding women, as well as to identify the actions in their social environment these women perceive as supportive in their breastfeeding processes. Data were collected through a qualitative approach, using recorded semistructured interviews, organized in accordance with the Collective Subject Discourse and analyzed under the premises of Social Representations Theory. Results showed that the representations of women in this study about support for breastfeeding consist of actions available in the hospital, family and work contexts. In these women's perspective, support is a broad phenomenon that involves aspects of encouragement, promotion and protection to breastfeeding.

Descriptors: breast feeding; social support; women's health

INTRODUCTION

Studies on breastfeeding support suggest the need for a structure to support women, so that they are prepared to overcome the difficulties and cope with the ambiguous feelings involved in the breastfeeding process^(1-6).

This is strengthened nowadays by the fact that, due to cultural, social and economic factors, breastfeeding is not a universally adopted practice. Although research in Brazil has revealed a growing trend in breastfeeding rates, these still remain distant from ideal levels.

Official programs do not seem to have incorporated progress yet in terms of knowledge production on women's breastfeeding experiences, illustrating the great distance between the developed concepts and clinical practice. Approaches centered on women and their experiences still remain theoretical constructions, which neither professionals in their practice nor health policy managers have learned a lot about⁽⁵⁾.

Breastfeeding promotion, protection and support actions need to incorporate elements of a new paradigm that take into account subjectivity and maternal individuality to reformulate the breastfeeding care model. Thus, one of the pillars of the breastfeeding consolidation movement among women in our society is support, which deserves special attention due to the lack of a conceptual structure to understand what actions, attitudes and practices in the field of professional relations or in the breastfeeding mother's environment can effectively support the breastfeeding process these women experience.

Considering breastfeeding as a socially constructed practice, it is questioned here if the support breastfeeding women are offered is not influenced too by mechanisms to communicate and construct the worldview of the social network that surrounds them in this process. It is also considered that it is woman herself who can best define the quality and composition of the support breastfeeding women need to be offered. They should be heard about their needs, so that this process is as successful as possible for both mother and breastfeeding infant.

Thus, this study aims to get to know the Social Representations of a group of breastfeeding women about support for breastfeeding and identify actions in the social environment these women perceive as supportive in their breastfeeding processes.

METHOD

Qualitative research principles were used to develop the study, characterized by enabling researchers to capture how individuals react to and think about the questions that are focused on, allowing knowledge on the dynamics and structure of the situation from the perspective of who is living it⁽⁷⁾.

The concept of Social Representation designates a form of specific knowledge, accessed through its cognitive elements (images, concepts, categories and theories), but understood through the context it is produced in⁽⁸⁾. Thus, social representations can be understood as forms of practical knowledge that guide daily actions at an interface with two forces: that of the contents circulating in our society and the force deriving from the social interaction process itself and pressures to define a given situation so as to maintain collective identities⁽⁹⁾.

METHODOLOGICAL PROCEDURES

The fieldwork was carried out at the Teaching Health Center Samuel B. Pessoa (CSE-Butantã), Butantã Health Coordination in São Paulo City, Brazil, between May and November 2007. This service not only performs important health care actions for the regional population, but also develops teaching at different education levels and in various professional areas, and is considerably active in health research.

Study participants were 14 women with children of up to 6 months old, without any restriction as to age, parity, socioeconomic condition, race or color, who were breastfeeding exclusively or not. The number of participants was defined by theoretical saturation of qualitative data, that is, the moment in simultaneous data collection and analysis when no more new and significant elements are perceived, thus reflecting the full range of dimensions one seeks to explain, in accordance with the objectives of this research.

The women were identified based on the regular appointments of children up to 6 months old at the pediatrics and child care sector. On this occasion, before the medical or nursing appointment, they were asked about their interest to participate in the study. After their acceptance and signing of the free and informed consent term, they were interviewed at a place that permitted both comfort and privacy. Initially, a questionnaire was applied to collected identification data, socioeconomic profile and breastfeeding situation as to type, frequency, duration and reason for introducing another food item or liquid into the baby's diet in case of non-exclusive breastfeeding.

Next, based on the guiding question "tell me what it has been like to breastfeed your baby since he was born until today", the interviewee's perceptions about support to breastfeed in the hospital context and at home were looked at in further depth, and also about her family and professional relations, asking her to explain situations in which she needed support and, finally, what she perceived as breastfeeding support.

The collected data were organized in accordance with the proposal of the Collective Subject Discourse, a technique that seeks to equip researchers to process the interviewees' answers to open questions, especially when one ultimately seeks to identify social representations⁽¹⁰⁾. Thus, the interviews were transcribed in full and the construction of the statements followed five steps: 1 - reading the interviews to get familiar with the general contents reported; 2 - identifying key expressions in each interview, which are extracts of the interviewees' speech pertinent for the research problem; 3 - attributing the central idea, which is characterized by the abstraction of the essence contained in each of the selected key expressions; 4 - joining the key expressions of central ideas with a similar or complementary sense and 5 - composing the full statements in the first person, which represent collective opinions on the research problem, with a title that summarizes the content of all key expressions joined there⁽¹⁰⁾.

The project was approved by the Research Ethics Committee at the University of São Paulo School of Nursing and at the Teaching Health Center Samuel B. Pessoa, in line with Resolution 196/96 on research involving human beings. The study objectives were explained and participants were guaranteed anonymity and secrecy of the research results. They were also informed that their participation in the research was voluntary.

CHARACTERIZATION OF THE WOMEN

The 14 women who participated in the study lived in the Butantã neighborhood. Ages ranged between 19 and 38 years, and mean education time was 7.5 years. Ten women had a paid job and worked in the service sector, specifically in care delivery and cleaning; three were unemployed and one was a housewife. Family income varied between 400 and 1,200 reais. As to breastfeeding performance, eight women gave exclusive breastfeeding (EB), one predominant breastfeeding (PB) and five breastfeeding (B).

RESULTS AND DISCUSSION

Based on the analysis of the verbal material, five discourses emerged on the breastfeeding experiences of the study participants, which revealed their representations on support within the hospital, family and work context, as well as the elements in the social environment they perceived as supportive.

The essence of the discourses was the acknowledgement of the support offered by professionals and partners, reports on welcoming through family organization, the experience of conflict, the search for support in planning their return to their professional activities and, finally, a synthesis of the women's reflections on what they consider as breastfeeding support.

From a psychosocial perspective, the postpartum period is considered a complex female experience, permeated by different changes, including attendance to the newborn's feeding needs. In actual practice, breastfeeding tests the elements of the woman's imaginary, confirming, strengthening or altering them through her experience, involving a series of maternal or newborn factors⁽¹¹⁾.

The reports of these women contained trajectories of overcoming the difficulties they faced to organize breastfeeding and perceptions on the support received in the hospital, family and work contexts. The scenario of support needs revealed the existence of a space for interpersonal relations and communication with their peers (husband, relatives and friends) and professionals, contributing to the elaboration of social representations about breastfeeding support.

Discourse - Support: the professional at your side

When she was born, my breast got very full, the milk came behind my arm, then they (nurses) came and taught me to massage, breastfeed both sides and always give milk until the end. In hospital, they gave me a lot of support, they explained me everything in detail (...). They came and helped, showed how we had to do it so the baby wouldn't take only the nipple, so as not to get hurt (...) if they hadn't helped me I wouldn't have breastfed, because it hurts at first. (...) I liked their care a lot, the way they taught. She says what you need to, I'm here at your side (E2, E3, E4, E6, E8, E11, E12, E13).

Their perception on the support received in the hospital context seemed to rest on effective interaction between the woman and the professional. The environment, information and the quality of the relation with health professionals made the women feel that their needs were attended to and that they received support.

A study on rooming-in care from the perspective of social representations shows that, depending on how the care relation occurs in the hospital context, the woman starts to re-elaborate her care representations. In this resignification movement, the hospital starts to be seen as a "place of help", making the woman feel welcomed, respectfully attended and well informed⁽¹²⁾.

In the hospital context, one can understand and translate the support the study participants reported as instrumental support, including practical help, knowledge transmission and breastfeeding encouragement.

The differential to perceive the hospital experience as positive and supportive of breastfeeding is the identification of affective elements involved in the interaction with the health team.

One may say that these findings are in accordance with the definition of support some authors propose, which can be understood based on the extent to which interpersonal relations are established that see to certain (material, informational, affective) needs, making individuals believe that they are wanted and part of a social network⁽¹³⁾.

With respect to the influence of support for the initiation and duration of breastfeeding, research has demonstrated⁽⁴⁾ that, although this may vary depending on the social and cultural contexts the woman is inserted in, formal support exerts positive influence on the initiation and duration of breastfeeding, and practical help seems to be the most effective means for health professionals to offer breastfeeding support.

Discourse - My husband is a companion

Even if the husband is not present, I think he is the person we most need support from. I have his full support, we talk a lot. Because at first I got kind of nervous, and what he said calmed me down, it helped me a lot, he said, it will get better tomorrow (...) he talked about how I wanted to be a mother and that gave me strength (...). He is a very dedicated father, he was very patient, he was the main incentive. (...) He is my true companion, if it weren't for his support I had stopped breastfeeding (E1, E3, E6, E8, E10, E13).

The husband's involvement in care, the dedicated attention, the manifestations of affections and joy meant a positive stimulus for the women in this study, giving them security and willpower to continue breastfeeding.

Authors affirm that the relevance of the father's participation is related not only to his role of playing and staying with the child, but also to the children's development and the family balance⁽¹⁴⁾.

Moreover, they believe that a large part of the quality of the father's involvement with the children and family is related with cultural and social factors, such as the valuation of gender equality, living with his partner, having a harmonious relationship, being part of an economic system that allows him to sustain the family and working cooperatively on housework⁽¹⁴⁾.

The study participants considered the partner's support actions an important element of support for breastfeeding, and these actions point towards the practical transformation of fatherhood towards socializing housework and sharing child care⁽⁶⁾. However, it was identified in their statements how much the husbands evoked the status of woman in the sense of valuing her or reminding her of the responsible experience of being a woman. This gives the idea that, by evoking this status, the husband/partner guides his attitude by his gender representations, translated as "the social construction of subjects as female or male", in which the idea of female nature is based on biological facts that occur in the woman's body, such as the capacity to carry children, give birth and breastfeed⁽¹⁵⁾.

The father's behavior can be a product of man and woman's socialization, deriving from a cultural and social construction society has legitimized for centuries, in which women are valued because of their biological capacity, with recommendations to take care of their children personally and, mainly, breastfeed them⁽¹⁶⁾.

Discourse - A support network is established for the woman to breastfeed

When I got home it was marvelous! Me and my daughter, we were received with a lot of affection (...) I felt welcomed (...). I get support, one person goes there to prepare some food, another to arrange things in the house and I don't need to stop breastfeeding, I can stay with her until she is satisfied. (...) My daughter helped me a lot to take care of her, clean the house, do the housework (...). My sisters always admire her, that helped me a lot, I feel more confident because there's someone with me. My mother is there on top of things all the time (...) she has done everything so that my breastfeeding is good (...). The sisters from church gave me everything, they bought food, clothes for the baby, everything I needed. I also have a good friend who is always there for me, mainly when I feel I need to unload, talk. My mother-in-law (...) is like a mother to me. (...) She is great, gives me emotional support and helps me in daily life (...). (E2, E3, E6, E7, E8, E11).

In this discourse, the descriptive essence reveals that the baby's arrival demanded strategies to cope with the new situation, not only from the mother but also from the family. A movement occurred to conciliate the former and new tasks, which entailed changes in the family organization.

The interviewees' report evidenced that the support to overcome the set of difficulties that have to be overcome in the private context, especially during the first weeks, comes from other women in the family. It seemed to be one of the decisive elements to face puerperal transformations, thus permitting the adaptation to the new reality of motherhood and favoring breastfeeding. This perception can be strengthened by other studies that also reveal family relations as an important reference for women in breastfeeding support, in which the family women's actions exert a decisive influence on support and care delivery to the puerperal woman and the infant⁽⁶⁾.

According to the women's statements, support from relatives and friends is based on an implicit valuation of women as breastfeeding mothers. One of the most relevant support elements in the family context was practical help, the fact that family members assumed tasks which, theoretically, woman assumes in the family dynamics, allowing her to dedicate more time to the baby and, consequently, to breastfeeding.

Another relevant element was emotional support, acknowledged by the relatives' manifestations of affection and fondness. In this respect, researchers⁽¹⁴⁾ affirm that these elements, which the woman perceives and receives, are fundamental to maintain her mental health, cope with stressful situations and periods of changes in her life.

The availability of relatives and friends to support the experience of motherhood allowed the women in this study to feel that their breastfeeding efforts were being acknowledged. The woman's protection by a family support network showed to be a relevant factor for the mother's behavior towards her children, which permits better conditions for the development of the mother-child relationship⁽¹⁴⁾.

Discourse - Seeking the right to breastfeed after getting back to work: where is the support?

I am going to take 4 months and 20 days of maternity leave, I have listed my name at kindergarten (...) I'm going to try to make him continue breastfeeding,(...) up to the age of 1 year, but I give a bottle sometimes, so that he gets used to it. Society does not support women who work and are breastfeeding. I know I am entitled to one hour per day to breastfeed (...) they (employers) put up more difficulty (...) if it were for my supervisor, who is breastfeeding would leave at the normal time. Sometimes I get stressed because she does not understand our side (...). I am suffering beforehand because, if I could, I wouldn't go back to work, but we can't (...). The biggest support society could give is if companies would stop seeing mothers as idle. (...) To achieve exclusive breastfeeding, the six-month maternity leave should actually become the law. After two months the mother already starts to give other foods, because she has to gradually adapt the baby's taste to go to kindergarten. It is a lot of suffering (E2, E5, E6, E7, E8).

Participants who worked indicated the need to return to their professional activities as the main reason to introduce other milk in the baby's diet before the age of 6 months. Researchers^(5,17) believe that conciliating breastfeeding with external activities is one of the most difficult female tasks in current society, as it involves conflict for decision making and, in daily life, the desire to be a good mother can clash with other roles the woman represents in society, such as that of a worker for example

According to the women's reports, three relevant points stand out in planning return to external activities: guaranteeing that the child will accept other food than mother's milk, guaranteeing/providing care for the child during her absence and dealing with the conflict of wanting/being able to maintain breastfeeding.

The early introduction of the bottle is considered a strategy women have found to minimize the impact of their distancing and gradually accustom the child to the absence of the mother's breast, besides testing and guaranteeing acceptance of other food⁽⁵⁾. In order to guarantee/provide care for their children during their absence, kindergartens were mentioned as the first option but, when faced with the impossibility of using this benefit, they sought other resources within their own family networks.

With respect to the work environment, the women who participated in this study also faced difficulties to maintain breastfeeding. Their statements reveal the employers' lack of knowledge or neglect of laws that protect motherhood, generating conflicts in the work relation and maternal anguish to stand on their rights. This acknowledgement indicates that breastfeeding promotion demands mechanisms that go beyond legal issues.

According to these women, society does not support women who work and breastfeed, which is not only a representation, but also an observation of the reality present in the lives of working women.

The participants' reports reveal that, when they feel pressured by their bosses, they outraged and in conflict, mediated by the pressure exerted by their immediate superior, knowledge about their rights and the satisfaction with breastfeeding.

In this sense, studies about issues related to breastfeeding and returning to work reveal that, for working women, "work does not forgive", indicating that breastfeeding women feel that pressure in the professional environment make their actions to maintain breastfeeding more difficult⁽⁵⁾.

One can infer that, in the public sphere, breastfeeding women find their role as mothers subject to the demands of the production sector, as if it were possible to break with the roles woman represents in society.

The study participants demand structural support that enables them to maintain and conciliate breastfeeding with their professional activities. There are few examples of companies who offer a support structure to maintain breastfeeding and lactation after return to work. When available, kindergartens are not always nearby and, in most cases, do not have trained staff to deal with children under exclusive breastfeeding.

The inconsistency of support in the home and work environments in order to conciliate breastfeeding and external activities makes it hard for women to maintain exclusive breastfeeding. Support from relatives, the partner, kindergartens and guaranteed occupational rights are still dubious, often entail more conflict and guilt than lighter work journeys and maternal responsibilities⁽⁵⁾.

Even if they have environmental conditions and material resources that favor this practice, women feel that human relations, in their private or public context, actually provide them with backup to adapt and put their projects in practice in order to continue breastfeeding. Different from support actions reported in other discourses, women who breastfeed and work feel alone to cope with issues related to the decision on conciliating the return to work with maintained breastfeeding.

In view of the representations of motherhood and the valuation of women as mothers, the study participants received support from their family networks to allow them to take care of their children. However, neither support movements by relatives or husbands were mentioned in order to conciliate professional activities with continued breastfeeding, nor the guarantee of care for their children when they go out to work.

Discourse - The perception about breastfeeding support

Support is important. Something we need both at home and outside. So that we have more energy to breastfeed.(...) Family support is important, and professional support too, but women need to want to breastfeed, so, when I don't find support, I look inside myself, I give myself support. I think breastfeeding is inside me (...) and knowing there's someone we can count on makes us feel at ease, someone who helps to take care of the baby, give a bath, arrange the house, the food, taking the children to school. It means someone to be there with you when you most need it, with experience in life, who listen and talks, giving emotional and psychological support. Support is affection from the partner, a word of consolation (...). If I didn't get support I think I would manage to breastfeed, but not the way I'm doing it (E3, E5, E7, E8, E9, E11, E13, E14).

The women's discourse reveals that they acknowledge the need for and influence of breastfeeding support in the private as well as public sphere.

It is interesting to highlight that, although women identify and acknowledge the need for support, they also represent the breastfeeding experience as unique and individual. In this perspective, support is considered a determinant factor in their experience, which gives them the opportunity to experience and develop self-confidence to live the experience in a more pleasant way.

Different breastfeeding support actions and their component elements were mentioned as significant to achieve the breastfeeding experience. Hence, from the women's perspective, support may be understood as a social phenomenon that covers a set of actions that should be offered as a whole and in accordance with their needs.

In the perspective of the study participants, breastfeeding support is related to the reality they live in and to the actions that give them the opportunity as well as the physical and emotional conditions to breastfeed. The experience of this reality presupposes the existence of interpersonal relations that value their maternal and female role in society, and of solid instrumental and structural support, allowing them to function as mothers and women in the public and private sphere.

FINAL CONSIDERATIONS

These study results reveal that support is a broad phenomenon, comprising already consolidated aspects, embedded in breastfeeding promotion, protection and support concepts and actions. According to the women's perspectives, support can be understood based on three dimensions: instrumental, affective and structural. In the hospital context, the instrumental dimension includes practical and informational elements on how to manage breastfeeding. In the family context, the instrumental dimension mainly refers to financial help and help with housework, allowing the woman to dedicate more time to the baby and to breastfeeding. The affective dimension covers elements of interpersonal relations, in the public and private context, emphasizing the way support is offered. The structural dimension refers to actions in the social context, especially access to kindergartens and opportunities to conciliate or maintain breastfeeding in the public space, particularly in cases of paid work.

The breastfeeding support actions society offers were not acknowledged, as opposed to obstacles to be overcome for these women to be valued in the professional environment as working women and mothers. The needs these women express represent a challenge, that is, the need to reconsider the practices of everyone involved in breastfeeding promotion, protection and support; therefore, health services should offer actions based on women's perceptions, attempting to establish a partnership with their family network, as well as integration with available social devices.

Recebido em: 24.3.2008

Aprovado em: 18.6.2009

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Publication Dates

• Publication in this collection
  30 Nov 2009
• Date of issue
  Oct 2009

History

• Received
  04 Mar 2008
• Accepted
  18 June 2009