ORIGINAL RESEARCH

Feeding and exclusive breastfeeding of newborns: social representation of fathers

Ihana Arrieche Fazio^I; Camila Daiane Silva^II; Daniele Ferreira Acosta^III; Marina Soares Mota^IV

^I Nurse. Member of the Research and Study Group. Federal University of Rio Grande. Rio Grande do Sul, Brazil. E-mail: ihanafazio31@gmail.com
^II Nurse. PhD. Professor, Federal University of Rio Grande. Rio Grande do Sul, Brasil. E-mail: camilad.silva@yahoo.com.br
^III Nurse. PhD. Professor, Federal University of Rio Grande. Rio Grande do Sul, Brasil. E-mail: nieleacosta@gmail.com
^IV Nurse. PhD. Professor, Federal University of Rio Grande. Rio Grande do Sul, Brasil. E-mail: msm.mari.gro@gmail.com

DOI: http://dx.doi.org/10.12957/reuerj.2018.26740

ABSTRACT

Objectives: to identify the structure and content of fathers' social representations of feeding and exclusive breastfeeding, and to analyze the structural relationships among these representations. Method: this qualitative study, based on Social Representations Theory, was conducted with 54 fathers on the maternity ward of a university hospital in south Brazil. Data collected through evocations from the stimulus-terms 'baby feeding' and 'exclusive breastfeeding', and semi-structured interviews, were treated using EVOC software and contextual analysis. The study was approved in Opinion No. 71/2016. Results: the word 'breastfeeding' appeared in the central nucleus of both stimulus-terms. In relation to 'exclusive breastfeeding', the words 'essential' and 'exclusive' were still present, demonstrating that his was inherent to health. Conclusion: fathers' representations were influenced by the meanings of cultural practices, but they acknowledge breastfeeding beyond its nutritional aspects, that is, they value the affective dimension of this practice.

Descriptors: Breastfeeding; father; parental involvement; nursing

INTRODUCTION

The experience of maternity brings significant changes to the woman's life¹, such as moments of doubts, fears and insecurities² . This experience includes the father, who also experiences new physical, emotional, mental and socio-cultural experiences resulting from paternity, as well as possible changes in his family nucleus³.

The National Policy for Comprehensive Care to Men's Health highlights the father's right to participate in the entire reproductive process, from the decision to have or not children to their education⁴. However, the influence of health professionals in directing responsibility only to women distances men from this process⁵.

The act of providing care is linked to availability, zeal and compassion⁶, a fact that is not restricted to the female gender. It comprises different beliefs, values, cultures and knowledge perpetuated ⁷ often within the family. In relation to the care of the newborn, this involves different popular practices such as the prayers against weakness, stomachache, to stop hiccupping and the use of teas for colic or fever⁸. With regard to breastfeeding, a study carried out in 2015 in the State of Rio Grande do Sul identified that puerperal women were encouraged by their mothers and grandmothers to put warm compresses and massage the breast during breast engorgement, as well as to use cocoa butter for skin cracks⁹.

Thus, these issues need to be discussed by health professionals, including the nurse⁷, thus favoring the clarification of such practices and stimulating the participation of the father in this stage of the children's life cycle. It is important that the nurse takes into account the parents' knowledge and popular practices, and clarifies them on the benefits and harms of each one, encouraging them to maintain the positive practices and proposing agreements to modify those harmful to the health of the newborn, especially those that negatively interfere in breastfeeding⁸.

Another common practice is early weaning, as evidenced in a survey conducted in Brazil between 1999 and 2008. This survey verified that the exclusive breastfeeding rate (EBF) among infants under six months was 41% in the Brazilian capitals and in the District Federal. The World Health Organization (WHO) recommends exclusive breastfeeding until the sixth month of life and complement up to two years or more¹⁰.

Breastfeeding is essential to the mother-baby binomial due to the nutritional, economic, immunological and emotional benefits¹¹. Strengthening of promotion, encouragement and support actions to EBF is of paramount importance to increase adherence and reduce child morbidity and mortality rates. In this sense, the qualification of the parents is indispensable in order to make them protagonists and responsible for the care with the newborn¹².

The participation of the father, together with the mother, in the care of the newborn improves the affective relationship, brings out feelings of satisfaction and encourages bonding with the children¹³. According to Law No. 13,275/2016, the paternity leave must be increased by 15 days, in addition to the five days already provided for in Federal Constitution/88, and may be extended in accordance with requirements, such as participation in a guidance program on responsible paternity¹⁴. This leave strengthens the father's participation in the care of the newborn, especially regarding the EBF.

In view of the above, considering the relevance of the EBF to the newborn, the importance of the participation of the father, the need for nurses to encourage breastfeeding and to know the father's representation on the subject, we ask: what is the father's social representation about feeding and EBF of the newborn? Thus, this research aims to identify the structure and contents of the fathers' social representation about feeding and EBF and to analyze the structural relationships between these representations.

THEORETICAL FRAMEWORK

In order to use the Theory of Social Representations (TSR) it is necessary to evaluate whether the object under study is a focus of representation of the participants. Such an assessment starts from the premise that the phenomena of social representation are everywhere, at all times in the cultural, collective and individual environment. Another premise is that an "object of study is only capable of generating representation if it has sufficient cultural relevance or social thickness" ^15:45, implying a peculiar relation between subject and object of knowledge¹⁶. This theory consists of a set of concepts, explanations of everyday life and interpersonal communications¹⁷.

Among the approaches of this theory, the structural one stands out¹⁵. This starts from the premise that the set of ideas, beliefs and opinions are organized around a central system, i.e., the Central Nucleus (CN), which is stable and more resistant to changes. The peripheral system has the function of protecting the CN; it contains the terms less frequently and less readily evoked, but significant to the representation¹⁸.

Exclusive breastfeeding permeates the reality of many families, including the father, and is present in the media and in the daily work of many maternity hospitals, especially in hospitals with a Child Friendly title. Thus, this study is based in the TSR because it is "a form of knowledge socially elaborated and shared, having a practical guidance and competing for the construction of a reality common to a social set"^19:22.

METHODOLOGY

This is a descriptive study with a qualitative approach, based on the TSR. The research was carried out in the maternity hospital of a university hospital in the southernmost region of the country. This unit receives an average of 80 mothers per month. Thus, participants were 54 parents who met the inclusion criteria, which were being father of newborn admitted in rooming-in in the maternity ward, accompanying the mother and aged 18 years or over. Parents who were under 18 years of age, those whose infants were hospitalized in the Neonatal Intensive Care Unit, those whose child gestation had evolved to miscarriage and whose the partner was unable to breastfeed.

Data collection took place between August and October 2016 through two techniques, namely free evocations and semi-structured interviews. In the first one, all the participants were asked to evoke five words or expressions in face of the inducing terms baby feeding and then exclusive breastfeeding.

After the free evocations, researchers performed the semistructured interview. In this part of the study, 30 fathers participated. According to studious on this theory, this is an adequate amount to obtain a representation²⁰. For that purpose, an instrument was elaborated containing questions related to the father's knowledge about EBF, his participation during EBF and the activities performed by him. There was a private room in the unit itself, and each interview had an average duration of 30 minutes; all the interviews were recorded and transcribed later.

For the analysis of the data, the software Ensemble de Programmes PemettantL'Analysedes Evocations 2005 (EVOC), created by Pierre Vergès in 1994, was used to organize the words, considering the frequency and order of evocation for the construction of the four-quadrant frame. This is formed by four quadrants, the Central Nucleus (CN) is located in the upper left quadrant. The contrast elements, which have a frequency less than the mean and a rang (position in which the word was evoked by the participant) lower than that established by the EVOC, are placed in the lower left quadrant. In the upper and lower right quadrants the first and second periphery elements are located, respectively. The most important peripheral elements, due to their high frequencies, are placed in the first periphery (upper right quadrant). The least frequent and least readily evoked elements are placed in the second periphery (lower right quadrant)²¹.

The interviews were treated through content analysis, by adopting, for the codification, the unit of context, which is broader and allows a better understanding of the meaning²². In this way, we searched in the interviews for the context in which the words contained in the four-quadrant tables were evoked, which gave birth to the category Baby Feeding and EBF. To ensure anonymity, the participants' speeches were identified by the letter F (Father) and the number that identifies the order of the interviews. The study design was approved under Opinion No. 71/2016.

RESULTS AND DISCUSSION

A total of 54 fathers with age ranging from 18 to 50 years old participated in the study, being the majority in the age group from 30 to 40 years. In relation to schooling, 23 parents had complete/incomplete Elementary School, 24 completed/incomplete High School and 7, complete/incomplete Higher Education. As for the civil status, 51 have lived with the partner and three have not lived with the partner. All of them had children and 15 had had at least one child from previous relationships.

The corpus composed of the evocations in face of the first inducing term, namely baby feeding, totaled 240 words, being 79 different. On a scale of 1 to 5, the average of the mean orders of evocation (rang) were 2.9, the minimum frequency was 6 and the mean frequency was 15. The analysis of the data resulted in the four-quadrant table, as shown in Figure 1.

FIGURE 1: Four-quadrant table formed by the evocation of fathers in face of the inducing term baby feeding. Rio Grande, RS, 2016.

O corpus formado com as evocações frente ao segundo termo indutor aleitamento materno exclusivo totalizou 187 palavras, sendo 93 diferentes. Em uma escala de 1 a 5, a média das ordens médias de evocação ( rang) foi 2,6, a frequência mínima foi 3 e a frequência média 7. A análise dos dados resultou no quadro de quatro casas, de acordo com a Figura 2.

FIGURE 2: Four-quadrant table formed by the evocation of fathers in face of the inducing term exclusive breastfeeding. Rio Grande, RS, 2016.

In investigating the father's social representation of baby feeding and EBF, we consider the reality and which meanings are attributed to a socially constructed set. Located in the upper left quadrant, the stable and change-resistant CN contains the most significant terms as they present high frequency and are more readily evoked¹⁸.

In the CN of the inducing term baby feeding onlybreastfeeding arose. Regarding the inducing termexclusive breastfeeding, the words essential and exclusive breastfeeding were referred to, as observed schematically by the Venn diagram, according to Figure 3.

FIGURE 3: Diagram illustrating the similarities and differences between the inducing terms infant feeding and exclusive breastfeeding. Rio Grande, RS, 2016.

Baby Feeding and EBF

Both representations have in common the term breastfeeding, evidencing that it is part of the baby feeding, even after introducing other types of foods. However, the nuclear terms essential and exclusive confer an inherent connotation to development, that is, something indispensable to their health, according to Figure 3. Some reports are:

Fathers recognize the benefits of EBF as a lower cost in food and that the baby becomes healthier and less vulnerable to illness²³. However, even when presenting a positive posture in relation to breastfeeding, it is common that fathers be absent from the moment in which this practice occurs by the puerperal woman. The breastfeeding process is still restricted to the female universe,²⁴ making the fathers' verbalization more idealized than translated into actions that strengthen the EBF process.

The elements of the periphery are flexible and accessible²⁰. They are in the upper right quadrant, the first periphery, and the lower right quadrant, characterizing the second periphery. In the first periphery, participants evoked the words "baby food", "food" and "fruit" in face of the inducing term baby feeding, demonstrating that according to the growth phase there are different solid contents in the baby's meal. Still, baby feeding is represented as a step after the EBF. See Figure 1. Here are the testimonials:

On the inducing term exclusive breastfeeding, the first periphery reinforced its central nucleus with the words health, development and growth. There is difference in the contents as well as significant use of abstract terms in the mental elaboration of this evocation. This condition reinforces that fathers understand EBF as essential, a biological condition important to the life of the newborn and that the object of study is recognized by them. See Figure 2. The speeches obtained were the following:

Breastmilk contains all the proper nutritional elements, plus the protection it gives both to the mother and to the baby. Breastfeeding assists in the prevention of morbidities in adult life, being relevant for the reduction of infant morbidity and mortality²⁵, development of orofacial tonicity, suction mechanism and correct mastication ²⁶, besides protecting the mother from ovarian cancer.

EBF should remain until the six months of age, without offer of teas, water and other foods²⁷. After this period, complemented breastfeeding can be maintained until two years, that is, complementary foods are introduced gradually, such as cereals, meats, vegetables and fruits. Parents should stimulate the consumption of vegetables and fruit and avoid foods rich in sugar, coffee, canned foods, soda, candies and fried foods in the first years of life²⁷.

In the second periphery of the inducing term baby feeding, fathers evocated the word yogurt more readily and liquids more often. Although fathers referred to baby feeding baby as something broad, that modifies according to the different phases of the development, some emphasized breastfeeding as part of the feeding, identifying it as a source of liquids, as shown in Figure 1. The speeches are below:

Faced with the inducing term exclusive breastfeeding, in the second periphery, the words immunity, formula, affection, love, baby, food and bond were evocated. The words food, formula and yogurt may indicate the influence of a culture that underestimates EBF. Affection, bond and love demonstrates appreciation of affectivity and recognition of the breadth of this practice, not only in view of the nutritional condition, but with a emotional connotation, according to Figure 2. The reports are as following:

The presence of the father has great potential to become a support in breastfeeding due to the influence on the mother and the feeling of protection of the newborn. The father seeks information on topics such as parent-child interaction, with breastfeeding being the least searched ²⁸.

A study carried out in the city of Goiânia, in the period of 2008 and 2009, identified some cultural practices during the EBF, among them, the ideas that the milk is not enough, weak and does not sustain the baby, besides the need for water and teas for children under six months. Still, the use of baby bottles and pacifiers was also responsible for the interruption of EBF²⁹.

The Child-Friendly Hospital Initiative (IHAC in Portuguese) aims to strengthen and increase the duration of breastfeeding, thus demonstrating positive impacts on the health of infants³⁰. To this end, it encourages the participation of the fathers in the care of the newborn. A study carried out in Porto Alegre in 2003 showed that the father wants to provide care and stay longer with the mother and the child in order to acquire experiences in the management of the baby³¹.

In the lower left quadrant there are the contrast elements, most predominantly cited, but less frequently. On the inducing termbaby feeding the following words are mentioned:formula, cow milk, essential, health and soup. The term formula is evoked as something negative and that should be avoided, encouraging the EBF, according to Figure 1. These are the speeches:

On the inducing term exclusive breastfeeding, the contrast elements were as follows: adequate, cow milk, mother, nutrient and baby food. It is noteworthy that the fathers recognize the difficulties that the mother faces during EBF and do not place them as the only responsible ones. See Figure 2. These are the speeches:

The divisions of daily tasks in the care of the newborn, especially with the insertion of the father or partner, can favor the maintenance of EBF ³². Paternal presence is an important ally due to his influence on the increase and incidence of breastfeeding³³. That is, the father interferes with the mother's decision to breastfeed and contributes to its continuity. Public policies need to include the family, especially the father, in maternal and child healthcare^34,35.

CONCLUSION

The social representation of the father about feeding and EBF of the newborn can influence the meanings of cultural practices and popular knowledge, but the scientific aspect is incorporated into this mental assimilation, translated by the benefits of EBF. The relationship between these representations was identified by its structures and content, revealing, in the central nucleus, breastfeeding as a common term. This is part of the child's diet, even after other types of foods are introduced.

Feeding of the newborn was represented as a phase after EBF, which involves the insertion of different foods according to the development stage and inclusion of liquids, yogurt and vegetables. The milk in an artificial formula was described as something negative and expensive.

When relating the representation of EBF, it was verified that it is essential and that it should be the exclusive food of the newborn. Fathers evoked terms such as healthy growth and development, lower chances of getting sick, natural immunity, and bond between mother, father and baby. The underestimating culture of EBF still persists, as can be verified by the terms evoked - food and yogurt. On the other hand, the fathers recognized that breastfeeding is important not only for its nutritional aspect, but also due to the affective sphere. They have also identified the difficulties. Among the limitations of the research, there is the scarcity of scientific studies that demonstrate fatherly participation and inclusion during breastfeeding, revealing a fragility in the search for knowledge about fathers' participation in this context. Still, the minimum participation of the fathers in the data collection period was mainly due to the workload, which also prevents them from staying longer with the mother and the newborn.

The nursing team needs to reflect on the social representations of fathers and partners, so that they can develop educational actions that allow the inclusion of the male gender in the breastfeeding process. Placing the father in the experience of maternity, encouraging him to exercise paternity and caring for the baby, as well as empowering the couple to practice EBF are actions that qualify assistance to the mother, father and child.

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