Pregnant relationship quality with the closest people and breastfeeding

ABSTRACT

Objectives

To identify the closest person to the pregnant woman, who acts as her primary support source, and evaluate the relationship quality through the instrument quality with the persons close to her and their influence on breastfeeding.

Method

Quantitative, descriptive, and exploratory study with a consecutive non-probabilistic sample of 152 pregnant women, in Health Units in a medium-sized municipality in the western region of Paraná, during the year 2019, to answer the research question “does the quality of the relationship between women in pregnancy and their primary source of support have implications for breastfeeding?. The “Quality of the relationship with the closest people scale - ARI” was used to obtain the data, which classifies the bond using points that can vary from 40 to 128, and the higher, the higher will be the quality of the bond with that person. The data were analyzed using descriptive statistics.

Results

Women identified the partner/husband (58.6%) and other family members (40.1%) as the most important and active people as their primary support source. The average score was 103.5, indicating that the relationship is healthy and positive aspects predominate.

Conclusion

The more positive the results, the greater the support received by the pregnant woman and, consequently, the greater the influence for the woman to initiate and maintain exclusive breastfeeding.

Implications for the clinical practice

The scale used can be applied regularly in primary care for nurses to identify fragile bonds that would influence breastfeeding.

Keywords:
Breastfeeding; Social Support; Pregnant Women; Women Health; Primary Health Care

RESUMO

Objetivos

Identificar a pessoa próxima à gestante, que atua como sua fonte de apoio primária, bem como avaliar a qualidade dessa relação por meio do instrumento qualidade da relação com as pessoas próximas e sua influência no aleitamento materno.

Método

Estudo quantitativo, descritivo e exploratório realizado com uma amostra não probabilística consecutiva de 152 gestantes, em Unidades de Saúde de município de médio porte na região Oeste do Paraná, durante o ano de 2019, para responder à pergunta de pesquisa “a qualidade da relação da mulher na gestação com a sua fonte de apoio primária tem implicações na amamentação? Utilizou-se, para obtenção dos dados, a escala “Qualidade da relação com as pessoas próximas-ARI”, que classifica o vínculo por meio de pontos que podem variar de 40 a 128, sendo que quanto maior, também maior será a qualidade do vínculo com aquela pessoa. Os dados foram analisados por estatística descritiva.

Resultados

As mulheres identificaram o companheiro/esposo (58,6%) e outros membros da família (40,1%) como as pessoas mais importantes e atuantes como sua fonte de apoio primária. A média do escore foi de 103,5, apontando que o relacionamento é saudável e predominam aspectos positivos.

Conclusão

Quanto mais positivos os resultados, maior é o suporte recebido pela gestante e, consequentemente, maior a influência para que a mulher inicie e mantenha o aleitamento materno exclusivo.

Implicações para a prática clínica

A escala utilizada pode ser aplicada com regularidade na atenção primária para o enfermeiro identificar vínculos frágeis que influenciariam a amamentação.

Palavras-chave:
Aleitamento materno; Apoio social; Gestantes; Saúde da Mulher; Atenção Primária à Saúde

RESUMEN

Objetivos

Identificar a la persona cercana a la mujer embarazada, que actúa como su principal fuente de apoyo, así como evaluar la calidad de esta relación por medio del instrumento cualidad de la relación con las personas cercanas a ella y su influencia en la lactancia materna.

Método

Estudio cuantitativo, descriptivo y exploratorio, realizado con una muestra consecutiva no probabilística de 152 gestantes, en Unidades de Salud de un municipio mediano de la región oeste de Paraná, durante el año 2019, para responder a la pregunta de investigación “¿la calidad de la relación de las mujeres en gestación con su fuente de apoyo principal tiene implicaciones para la lactancia materna? La escala “Calidad de la relación con personas cercanas - ARI” se utilizó para obtener los datos, que clasifican el vínculo mediante puntos que pueden variar de 40 a 128, cuanto mayor sea la calidad, mayor el vínculo con esa persona. Los datos se analizaron mediante estadística descriptiva.

Resultados

Las mujeres identificaron a la pareja / esposo (58.6%) y otros miembros de la familia (40.1%) como las personas más importantes y activas como su principal fuente de apoyo. El puntaje promedio fue de 103.5, lo que indica que la relación es saludable y predominan los aspectos positivos.

Conclusión

Cuanto más positivos sean los resultados, mayor será el apoyo recibido por la mujer embarazada y, en consecuencia, mayor será la influencia para que la mujer inicie y mantenga la lactancia materna exclusiva.

Implicaciones para la práctica clínica

La escala utilizada puede aplicarse regularmente en la atención primaria para que las enfermeras identifiquen los vínculos frágiles que influirían en la lactancia materna.

Palabras clave:
Lactancia Materna; Apoyo social; Mujeres Embarazadas; Salud de la Mujer; Atencion Primaria de Salud

INTRODUCTION

Breastfeeding (BF) is not only a practice of child nutrition; it also involves processes that strengthen the bond between mother and child and bring significant benefits to both. It also improves the quality of life of families, since it reduces the incidence of diseases and all their implications.¹ Moreover, it promotes economic increases for a country, either by increasing the child's intelligence quotient (IQ), or by reducing health care costs and/or by having environmental sustainability and not causing pollution, waste, or the use of unnecessary packaging.²

However, there are many determinants that act in the context of breastfeeding and that need to be considered and evaluated in order to be successful in this practice, namely: biological, economic, social, cultural and psychological factors.³

In this context, social support networks are composed of actors close to women, that is, primary sources of support that provide them with support and can influence positively or negatively their decision to breastfeed and, therefore, should be considered as determinants in the adherence and maintenance of breastfeeding.⁴

Social support is considered a psychological and emotional support tool for women during pregnancy and later in the puerperium.⁵ It can be presented as emotional, material and financial support and also involves help with household tasks, baby care and other children.⁶ In this regard, several studies investigate the social support network of pregnant women and women who have recently given birth that can influence the practice of breastfeeding, as evidenced by research that the family environment and people in the community context, especially women, are the main sources of support for this network;4 and that the advice provided by the husband/ partner and mother represent important support and help to deal with difficulties and discomfort that may arise, reinforcing the practice of BF⁷ They have also shown that people who are not family members, but who live with the woman, such as friends, neighbors, father of the child who does not live with her, work colleagues, among others, act as social actors in the network, especially for those who do not have close relatives.⁶

However, from the context described above, it can be seen that, among the studies aimed at identifying women's social support network in pregnancy and their relationship with breastfeeding practice, few evaluate and/or discuss the importance of the quality of this relationship and the actions of health professionals needed to strengthen it in relation to breastfeeding practice. It is important to highlight that in this new phase of being a mother, the mother often feels incompetent and incapable for the act of raising her child and, most of the time, does not have the emotional or physical support of the people around her. On the contrary, what she often receives are opinions that discredit her as a woman and as a mother.⁸

Therefore, the study is based on the following guiding question: Does the quality of a woman's relationship during pregnancy with her primary source of support have implications for breastfeeding? In order to answer this question, the objective was to identify the person close to the pregnant woman, who acts as her primary source of support, as well as to evaluate the quality of this relationship through the instrument quality of the relationship with the people close to her and their influence on breastfeeding.

METHOD

The study is part of a multicentric project called 'Exclusive breastfeeding: sociocultural determinants in Brazil', under the coordination of the Anna Nery School of Nursing at the Federal University of Rio de Janeiro (EEAN-UFRJ), which in turn is part of international research on BF in the Americas, called 'Exclusive breastfeeding: sociocultural determinants in Latin America.’

It is a quantitative, descriptive and exploratory study conducted with a non-probabilistic consecutive sample of 152 pregnant women, attending Health Units in a mid-sized municipality in the western region of Paraná, on the occasion of the prenatal consultation and with follow-up up to six months of the baby's life. The choice of health units, in which data were collected from pregnant women, was based on a report from the epidemiology sector of the municipality, identifying those units with the highest number of pregnant women registered in 2018. The sample inclusion criteria were being a pregnant woman with gestational age between 30 and 37 weeks, with habitual and/or intermediate risk (registered in the medical record and/or in the pregnant woman's card), Brazilian and aged 18 years or older.

Os dados foram coletados pela equipe de pesquisa, composta de mestrandos e alunos de iniciação científica de graduação em Enfermagem, durante o ano de 2019, por meio da escala “Qualidade da relação com as pessoas próximas”, traduzida e validada para o português do Brasil pela equipe de pesquisa da EEAN-UFRJ,⁹ a partir da escala em espanhol Calidad de la relación com su persona cercana.¹⁰ Originalmente, essa escala foi desenvolvida por Hall (1983), na versão inglesa Autonomy and Relatedness Inventory (ARI).¹⁰ Tanto nas versões em espanhol quanto em português, a sigla da escala na língua inglesa (ARI) foi mantida. Quality of the relationship with your close person

The data were collected by the research team, composed of master students and undergraduate students in Nursing, during the year 2019, through the scale “Quality of the relationship with the people close to us”, translated and validated into Brazilian Portuguese by the research team of the EEAN-UFRJ,9 from the scale in Spanish Quality of the relationship with your close person.¹⁰ Originally, this scale was developed by Hall (1983) in the English version Autonomy and Relatedness Inventory (ARI).¹⁰ In both the Spanish and Portuguese versions, the acronym of the scale in the English language (ARI) was maintained.

The original scale (in English) was composed of items belonging to the Marital Autonomy and Relatedness Inventory (MARI), built by Shaefer and Edgerton (1979) and evaluates the quality of marital relationships; and from then on, Hall (1983) added eight items to evaluate support and listening, a measure based on early definitions of social support and concepts of interpersonal relationships, as well as recognition of the need to evaluate the unfavorable side of close relationships.¹⁰

Thus, Autonomy and Relatedness Inventory (ARI) is a scale of 32 items, divided into eight sub-scales: Acceptance, Kinship, Support, Listening, Autonomy, Control, Hostile Control and Disengagement/Rejection. These, in turn, are grouped in a two-dimensional factor structure: Support/Positive Attitude with 20 items, considered positive and Domain/Control with 12 items, considered negative.¹⁰

The adapted scale, both in the Spanish version (Autonomy and Relatedness Inventory - Spanish version) and in the Brazilian version (Quality of the relationship with the people close to us) was maintained with 32 items and produced the same factorial structure as the ARI - English, with two dimensions: one positive and one negative.^9,10 The Support/Positive attitude dimension is represented by items 1, 3, 4, 5, 7, 9, 11, 13, 15, 16, 17, 19, 21, 23, 24, 25, 28, 29, 30 and 31; and Domain/Control is represented by items 2, 6, 8, 10, 12, 14, 18, 20, 22, 26, 27 and 32. In the Brazilian version, the scale presented content validation index of 0.92 and Cronbach's alpha 0.869.⁹

In order to collect data, the coordinators of the health units selected for the study were first contacted by telephone to obtain the dates and times of the unit's agenda for care of pregnant women, since the approach occurred concomitantly to their attendance for care

The invitation to participate in the study was made to those pregnant women who fit the criteria for inclusion in the research, before or after their medical and/or nursing consultation. The pregnant women who accepted to participate in the research were sent, individually, to a room made available by the health unit, with the purpose of maintaining privacy, at which time they were explained in detail the research and its objectives, as well as the request, after expressing agreement, to sign the Free and Informed Consent Term - FICT, for later collection of data from the research.

In the data collection, first the participants' sociodemographic characterization form was applied and then they were asked to identify the most important person in their lives, to whom they felt closest. They were then asked to describe their perception of intimate behavior in relation to each item on the scale, based on a five-point Likert scale, ranging from (1) “no, never” to (5) “very much, always”. For the analysis, the item values were recoded from 1 (zero), 2 (1.0), 3 (2.0), 4 (3.0), 5 (4.0). To calculate the total score, the values corresponding to the numbers marked were added, and the cumulative score can vary from 0 to 128, meaning that the higher the score, the greater the positive perception of the relationship with the person.^9,10

The data collected were systematized in a spreadsheet matrixed by the multicenter study, directly in the Statistical Package for the Social Sciences (SPSS), version 23.0, with double typing and conference. Descriptive analysis, central tendency (median and mean) and variability (standard deviation), according to each variable (categorical or continuous) were performed. The reliability of the scale used was evaluated by the internal consistency of its items, measured by the Cronbach's Alpha Coefficient, being considered with evidence of reliability the values above 0.70.¹¹

The research project was approved by the Research Ethics Committee of the Anna Nery School of Nursing, under opinion number 2,507,525 and CAAE: 80711517,8,1001,5238 on February 22, 2018.

RESULTS

Among the 152 participants in the study, the average age was 25.6 years, with an average of 25 years, ranging from 18 to 40 years, of which they were predominantly white (51.7%), lived with a partner or spouse (84.9%), worked outside the home (54.6%) and had no health plan (80.9%). They also mentioned that family income was sufficient for basic needs (72.4%); they did not smoke (92.1%) and did not drink alcohol in the last 3 months (87.5%), according to Table 1.

Table 1
Sociodemographic characterization of study participants. Cascavel, PR, Brazil, 2020. (n= 152)

Variable	n (%)	(%)
Ethnicity
White	78	51.7
Brown	60	39.7
Black	10	6.6
Yellow	3	2.0
Marital Statue
Lived with partner	129	84.9
Married	111	73.0
Works outside the home	83	54.6
Health Plan (no)	123	80.9
Family income
Enough for basic needs	110	72.4
More than enough for basic needs	31	20.4
Less than enough for basic needs	11	7.2
Non-smoker	140	92.1
Hasn't ingested alcoholic drinks in the last three months	133	87.5

• Source: Research database.

In relation to the most important adult person, to whom she referred regarding the ARI scale issues, the “partner or spouse” was the most mentioned person (58.6%), according to Table 2.

Table 2
Most important adult person for the pregnant woman, who acts as her primary support source. Cascavel, PR, Brazil, 2020. (n= 152)

Person mentioned	n	%
Companion or spouse	89	58.6
Another family member	61	40.1
Other person not a family member (friend)	2	1.3

• Source: Research database.

The ARI scale items with their answer choices are described in Table 3, highlighting the most frequent answers, marked in bold.

Table 3
ARI scale answers. Cascavel, PR, Brazil, 2020. (n= 152)

Item of the scale	No, never (%)	A little (%)	Sometimes (%)	Very (%)	Very much/ Always (%)
1) Talk about your problems with me	3.3	9.9	13.8	19.7	53.3
2) You are always trying to change me	40.8	16.4	24.3	5.3	13.2
3) Respect my opinions	2.0	6.7	26.0	24.7	40.7
4) Act as if I bothered you	80.3	11.2	7.2	1.3	0
5) It's there when I need it	0.7	0.7	3.3	13.8	81.6
6) Does not take no for an answer when he/she needs something	56.3	11.9	23.2	2.6	6.0
7) Try to understand my point of view	2.0	3.3	17.8	27.6	49.3
8) Give me all the freedom I want	5.9	4,6	21,1	22.4	46.1
9) You are always thinking about things to please me	2.6	3.3	14.5	25.0	54.6
10) Discuss, no matter what I want to say to you	59.9	13.2	19.7	2.0	5.3
11) Encourages me to follow my own interests	2.6	4.6	14.6	18.5	59.6
12) He (a) laughs (mocks) at me	72.8	4.6	13.9	2.0	6.6
13) Is very willing to help me when I need it	0	0.7	5.3	14.5	79.6
14) Wants to have the last word on how we spend our money	63.8	11.2	16.4	2.0	6.6
15) Do you think it is worth listening to me	0,7	3.3	21.7	22.4	52.0
16) Allows me to change my mind	4.6	0.7	30.3	21.1	43.4
17) Have a good time with me	0.7	8.6	10.6	24.5	55.6
18) Wants to control everything I do	68.4	14.5	9.9	1.3	5.9
19) Be happy to support my decisions	3.3	2,6	16.4	23.0	54.6
20) He/she says that I am a problem for him/her	91.4	3.9	2.6	0	2.0
21) Do what you can to make things easier for me	0.7	2.0	7.9	21.1	68.4
22) You expect me to do all things your way	59.2	16.4	13.8	3.3	7.2
23) It makes me feel like I can tell you whatever I want	4.6	6.6	17.1	15.8	55.9
24) He thinks it is okay not to agree with him/her	15.8	13.8	27.0	13.8	29.6
25) He asks me to share with him/her the things he/she likes	3.9	2.6	11.2	21.1	61.2
26) Always finds defects in me	63.8	14.5	16.4	2.0	3.3
27) Consider my point of view	1.3	3.9	22.4	26.3	46.1
28) Don't think about me	77.6	5.3	3.3	5.9	7.9
29) Try to console me when things are not going well	3.9	0.7	4.6	23.0	67.8
30) Act as if you don't know me when you are bored	77.5	7.9	7.9	3.3	3.3
31) Would you like me to tell you when something is bothering me	3.9	2.6	9.2	21.1	63.2
32) Let me do anything I want to do	7.2	6.6	34.2	21.7	30.3

• Source: Research database.

The ARI evaluation is presented in Table 4, both the values of the total of the scale (total ARI), as well as of its two dimensions (Support/Positive Attitude and Domain/Control).

Table 4
Distribution of total ARI scores and their dimensions. Cascavel, PR, Brazil, 2020. (n=152)

Items	Number of items	Average ± S.D	Median	Variation	Alfa de Cronbach
Support / Positive attitude	20	58.6±9.9	60.0	21 a 72	0.87
Domain/Control	12	37.9±7.3	39.0	12 a 48	0.77
Total ARI	32	103.5±15.9	106	40 a 128	0.89

• S.D.= Standard Deviation

In the support/positive attitude dimension, it was observed that more than 50% of the participants pointed out that this relationship presents positive aspects, such as support, listening, acceptance and autonomy. In the same way, when more than 70% of the women pointed out the option “No/never” for the questions “acts as if I bother you”, “doesn't think about me” and “acts as if you don't know me when you are bored”, one has the reinforcement that the quality of this relationship is healthy.

Regarding the Domain/Control dimension of the ARI scale, it was found that of the 12 items, eight were answered by more than 50% of the participants with the “never” option, which were: don't take no for an answer when you need something, discuss, no matter what I want to tell you, laugh (mocks) at me, want to have the last word on how we spend our money, want to control everything I do, say that I'm a problem for him/her, expect me to do everything in his/her way and always find defects in me. These answers point to a relationship based on acceptance, understanding, respect and detachment, reinforcing the positive aspect of the relationship.

The other items did not present answers with significant percentages, but 40.7% answered “very much/no time” for the item “respects my opinions” and 46.1% for “considers my point of view”. However, in the item “let me do anything I want to do”, 34.2% pointed out the option “sometimes”, which can give rise to a dubious understanding of the question, as it is comprehensive, with different interpretations.

The use of answers to evaluate, in a median way, someone or something by means of an instrument can be a quick and apparently safe solution of choice, in which the individual does not position himself/herself exactly, does not compromise; or on the contrary, expresses a doubt. Still, probably because it is the point that the respondent does not have to try to analyze and respond.¹²

As the result of the two dimensions, the average values of the Support / Positive attitude dimension were 58.6 points, ranging from 21 to 72 and Cronbach's alpha of 0.87. For the domain/control dimension, the average was 37.9, varying from 12 to 48 points and Cronbach's alpha of 0.77. In the total evaluation result of the ARI scale, the score presented an average of 103.5, varying from 40 to 128 points and Cronbach's alpha value of 0.89.

DISCUSSION

Similarly, to this study, a survey of 100 Hispanic women living in the United States found that 57% of the group identified their partner as the primary intimate relationship, 32% the mother and 11% other family members, including the father and sister.¹⁰

The fact that almost all women live with their partner or spouse may justify this main indication as the most important person. In this regard, partner support is pointed out as the main form of participation during the gestational period and goes beyond just financial support, since it includes emotional contribution.¹³

The literature points out that healthy love relationships are based on respect and trust, and their quality is directly related to positive affections and marital satisfaction, and can become an important factor in mental health protection.¹⁴ As in this study women have the presence of their partner, this can be a protective factor for their mental health, which in turn could contribute to their confidence in conducting themselves with their child.

Also, in this context, being the partner/spouse frequently mentioned among the most important people for women, research conducted in the northwestern region of Paraná identified that the partner/ father recognizes the importance of his support for the success of breastfeeding, especially in relation to his presence with the mother and baby, help in domestic tasks, care of the baby and attempts to alleviate the difficulties experienced during breastfeeding.¹⁵

These data are like the ARI scale responses, in which the women stated that the person mentioned is always present when she needs it, willing to help her, to stay with her, doing everything possible to make things easier. Similarly, a study reveals that the fact that women are accompanied by their husband or partner seems to have a positive influence on the duration of breastfeeding.¹⁶

On the other hand, although the spouse is pointed out as the greatest source of support in our study, authors identified that, when breast intercurrences occur, they do not offer this support,¹⁷ because they did not receive orientation during prenatal care on this topic, which would help them understand the situation and the difficulties of this process.¹⁵ Thus, it is essential that prenatal care be centered on the family, that the person considered most important to the woman be identified and participate in all events held in this scenario. Therefore, it becomes necessary to rethink the forms of health care, stimulate and facilitate the participation of these social actors in the process.¹³

Still on this theme, understanding social support as emotional and instrumental support,¹⁸ when correlated with social support and conjugal relationship, it became evident that the more positive the relationship between peers was, expressed by affection, communication between the couple, good things that the partner does, among other characteristics, the greater were the social supports available to them, since the conjugal relationship can affect other interpersonal relationships and influence the search and request for support within the family or social context.¹⁹ Thus, the answers provided by the women in the study point to a pleasant conjugal/family relationship with greater availability of social support.

As the result of the two dimensions, similar values were found in the study of Linares, Hall and Ashford (2015), in which Cronbach's alpha was 0.91 for the Support/Positive Attitude dimension and 0.82 for the Domain/Control dimension. For the total scale the average was 108.8, ranging from 59 to 128; and Cronbach's alpha value was 0.92, indicating its strength to measure the quality of a primary intimate relationship in that sample.¹⁰

The descriptive values of the ARI scale demonstrated that, predominantly, women had a positive relationship with their primary source of support. Research conducted with the purpose of identifying pregnant women's perception of the family support received during the pregnancy and puerperal period showed that most of the women interviewed had a positive perception of the support received and valued family involvement during this period, which positively influences the prenatal, childbirth, and puerperal periods, including breastfeeding.¹⁶ By relating to their social network during breastfeeding, nurturers expect to receive understanding and support and point to the intention of maintaining these relationships with a positive aspect in order to overcome difficulties and achieve success in breastfeeding.²⁰ A positive relationship with a person considered a source of primary support can positively influence the initiation and maintenance of BF.

For this purpose, using tools that help in the identification of primary support for the pregnant woman in primary health care allows the health team to direct its actions with focus on care beyond women, considering their established links. In this investigation, the ARI scale proved to be an effective method to evaluate the quality of a relationship with a close person, because when its results are positive, the greater the support received by the pregnant woman and, consequently, the greater are the influences for the woman to start and maintain exclusive breastfeeding (EBF). On the contrary, when the result is negative, the health team can dedicate itself to building this relationship in the family for the support that the woman will need during pregnancy and after the birth of the baby.

CONCLUSION AND IMPLICATIONS FOR PRACTICE

The results of this research showed that pregnant women identify their partner/spouse and other family members as the most important people and that they act as their primary source of support, demonstrating the need to develop family-centered health care. This is not a new issue for Nursing, nor for primary care, however, it remains on the agenda of pending issues related to the quality of prenatal care in the country, impacting the numbers of maternal-infant mortality.

In the results of the ARI scale, it was found that the quality of the relationship with the close person is healthy and has positive aspects, since many issues addressed involving characteristics of support, listening, autonomy, acceptance, understanding and respect were answered positively. It is suggested its use in the primary care units for the identification of the primary support of pregnant women and the Nurse's performance in the strengthening of the bonds for the necessary support to the woman in the pregnancy and puerperal period.

The study presents limitations such as the non-randomized sample, the non-inclusion of other evaluations, such as the health team, and the absence of instruments to evaluate the support to the pregnant woman in Portuguese language. For this reason, the comparison with the other instruments used to evaluate breastfeeding during pregnancy made other types of correlation analysis between the support received and the EBF impossible.

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• ¹
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Edited by

ASSOCIATE EDITOR

Stela Maris de Mello Padoin

Publication Dates

• Publication in this collection
  27 Nov 2020
• Date of issue
  2021

History

• Received
  20 May 2020
• Accepted
  22 Sept 2020