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Abstract

Background

The success of breastfeeding among post-cesarean- section mothers requires strong willingness and commitment, self-confidence, support from various professionals, and internal support (especially from their husband) and the belief and value of their family. Exclusive breastfeeding remains low in some cities such as in West Java, especially in post-cesarean-section mothers, who are influenced by certain factors. The purpose of this study is to identify husbands’ role and their support for post-cesarean-section mothers in exclusive breastfeeding.

Design and Methods

This study used a qualitative phenomenological approach. with a combination of different data collection techniques: focus group discussion and in-depth interviews. Twelve husbands of post-cesarean-section mothers participated in this study. Data were analyzed by thematic content analysis.

Results

Four themes were identified namely knowledge about exclusive breastfeeding, the role of the father during breastfeeding, the experience of the husband and the family in supporting breastfeeding, and Women's lack of knowledge, inconvenience due to pain as the most impending factors of exclusive breastfeeding.

Conclusion

Most fathers seem eager to be involved and assist their partners to give breastfeeding to their baby. Furthermore, adequate support from family members, health care professionals, and employers can enable fathers to encourage and help their partners initiate and maintain exclusive breastfeeding. Fathers’ emotional, practical, and physical supports are also important factors that promote successful breastfeeding and enrich the experience of mothers.

Keywords

Fathers’role Post-cesarean-section mothers Sustainability of breastfeeding

Introduction

Breast milk is a nutritious standard food recommended for babies because of the short and long-term medical and non-medical benefits obtained for both infants and mothers of breastfeeding. ¹ The World Health Organization (WHO) and the Ministry of Health recommended an exclusive breastfeeding during the first 6 months of child's life, followed by complementary food until the child is two years old or beyond. This actions can prevent the occurrence of body failure (stunting) and the risk of infectious diseases, including diarrhea, respiratory diseases, ear infections, and urinary infections among children.² The practice of exclusive breastfeeding in Indonesia increased from 54% in 2012 to 61.33% in 2017, but not all regions have been following this change; for example, in West Java and Banten, the breastfeeding coverage rate remains below the national coverage rate (55.4% and 87%, respectively).^3,4 Those that from mothers themselves, psychosocial, cultural, and socioeconomic factors and from external for example families and community. Culture is a key component factors in breastfeeding, but it is relatively unexplored.^5,6

Significance for public health

The incidence of cesarean sections in Indonesia continues to increase in both government and private hospitals because of the higher complications that occur in pregnancy with some effects of post-partum condition including the breastfeeding process. Increasing the incidence of cesarean sections also affects breastfeeding mothers’ post-cesarean-section behavior. The successful of breastfeeding among post-cesarean-section mothers requires strong willingness and commitment, self-confidence, support from various professionals, and internal support (especially from their husband) and belief and value of their family This study indicates a significant relationship between husbands’ role and their support for post-cesarean-section mothers in exclusive breastfeeding. This study can provide new insights for family members especially spouse, health care professionals to encourage and help their partners initiate and maintain exclusive breastfeeding.

Preliminary research conducted by Budiati and Setyowati on 148 postoperative cesarean mothers showed that as many as 84% of post-cesarean-section mothers have excellent knowledge regarding exclusive breastfeeding, but only 23.3% exclusively breastfeed; one factor that affects them is lack of support from their husbands.⁷ This is in line with several studies that suggest that fathers’ support has been empirically proven to have a strong influence on mothers’ decision to start and continue breastfeeding.^8–10 A study suggested how nursing mothers identify their husbands as their main source of support for continuation of breastfeeding, but little is known about the nature of the support provided.¹¹

The role of fathers is a significant factor in supporting breastfeeding, but little has changed in breastfeeding practice over the following years.¹²A study on the predictors of breastfeeding plans among low-income women found that perception of social support significantly strengthens a mother's intention to breastfeed.¹³ A systematic review of qualitative studies on breastfeeding concluded that most mothers consider informal social support (received from partners and parents) to be more important than formal support (received from health care staff, such as doctors, nurses, and lactation consultants).¹⁴ A mother who has a close kinship network with family members, including the baby's father, his mother (baby's grandmother), other family members, friends, and colleagues does not always receive the expected support in giving breastfeeding.¹⁵ Some mothers feel embarrassed to breastfeed give form, so that they give formula milk because of massive commercial advertising of formula milk. Mothers’ work and social affairs also influence the continuity of breastfeeding.¹⁶

The incidence of cesarean sections in Indonesia continues to increase in both government and private hospitals because of the higher complications that occur in pregnancy with some effects of post-partum condition including the breastfeeding process.¹⁷ Increasing the incidence of cesarean sections also affects breastfeeding mothers’ post-cesarean-section behavior. Rowe-Murray and Fisher stated that cesarean delivery results in delayed initiation of early breastfeeding. ¹⁸ Mothers who deliver by cesarean section rarely experience skin-to-skin contact with their babies.¹⁹ Some studies show that mothers with vaginal delivery have a higher rate of breastfeeding during hospitalization up to 6 months after birth.^20–23

Problems with breastfeeding, such as low production of breast milk in the first days after childbirth, hinder early breastfeeding. According to Gatti, the problem of mothers who breastfeed their babies in the first days of breastfeeding is caused by anxiety and fear of lack of milk production, and lack of knowledge about the breastfeeding process.²⁴

Design and Methods

This qualitative research method is used in this study. A phenomenological approach with a combination of different data collection techniques: focus group discussion and in-depth interviews. This design facilitated the paternal emic perspective, allowing the researcher to explore the inside world of the fathers’ thoughts and beliefs regarding the enabling and impeding factors of breastfeeding practices without making any judgments. In addition, researchers made field notes. Field notes helps to better ensure a comprehensive description on the attainment of the results and the accuracy of the description. Twelve participants (husband of postoperative cesarean mothers who life in West Java) have participated in this study. The sampling was purposive sampling. Participants were selected who fulfilled the following criteria including: (a) age of 18 years or older, (b) fathers or couple of post cesarean section wife, (c) ability to speak bahasa, and (d) life in the same house with the breastfeeding mother. The sample included breastfed infants’ range in age between one to 12 months. They are four participants who excluded from this research because the fathers whose infants have any type of illness or complications in birth, including prematurity, congenital abnormalities and were not undergoing any medical treatment.

Qualitative data were analyzed using thematic content analysis. ²⁵ After we analyzed the specific statements or key words to give a full picture of their experience of the phenomenon under study, we made a list of significant statements and grouped them into larger units or themes.²⁶

Results

The participants’ ages ranged from 22 to 48 years. The majority of the fathers were Sundanese and college graduates. They experienced a number of practical support strategies namely assisting with meal preparation, housework (such as dishwashing and laundry), shopping; bathing the baby; bringing their child to the mother for nighttime feeding; and doing things to help the mother relax (such as neck massages) as well as emotional support.

This finding revealed four themes of the experiences of fathers living with partners who are breastfeeding their infants after cesarean deliveries namely: i) knowledge about exclusive breastfeeding, ii) role of fathers in breastfeeding, iii) husbands’ and families’ support for breastfeeding, and iv) Women's lack of knowledge, inconvenience due pain as the most impending factors of exclusive breastfeeding.

Discussion

Theme 1. Knowledge about exclusive breastfeeding

This theme supported by three categories: (a) knowledge of the advantages of breastfeeding, (b) risk of formula, and (c) low cost and high efficiency of breastfeeding.

Knowledge of the advantages of breastfeeding

All participants understood the benefits of breastfeeding for his wife and child, as two out of twelve participants’ statement as follow:

“Our baby knows when my wife is not happy. The baby always cries. Just having the baby feel loved is really a major thing.” (P3)

“My parents said that, if the mother breastfeeds the baby, the child will be easy to raise and more loving to their parents in the future. One of the advantages of it is that he has never been sick.” (P5)

Risk of formula

Participants also aware about the risk of giving formula milk to the baby, for example two out of twelve participants stated the following:

“I have read about the dangers of formula milk from several media and discussions with some more experienced friends. Formula often causes diarrhea in babies. Some cannot defecate easily. The nutritional composition is also not enough for babies.” (P6, P8)

Low cost and high efficiency of breastfeeding

Most of the participants stated that breastfeeding can affect and helping their families’ budgeting and expenses, as two out of 12 participants said:

“There are a lot of good things about [breastfeeding]. Expense-wise, obviously, you don't have to buy formula each week.” (P6, P8)

Theme 2. The Role of Fathers in Breastfeeding

The theme was supported by three categories: (a) responsibility for the families’ functions, (b) partnership in decision-making and spending time with their baby, and (c) giving of precedence to the mother's choices.

Responsibility for families ‘functions

All participants expressed positive opinions on breastfeeding. The couples choose the breastfeeding as main food of their baby. The majority of these participants aware benefits of breastfeeding and they got information from prenatal classes and from their families and friends, for example some statements of the participants:

“Through prenatal classes, we were both trained in small workshop [in favor of breastfeeding].” (P5, P8, P10, P11)

Partnership in decision making and spending time with their baby

Some of the fathers were highly committed to breastfeeding, stood by this method of feeding, and enjoyed discussing the benefits of breastfeeding, even when their families or spouses did not share their enthusiasm. Their stand was also driven by information that they had received, which further enhanced the value they placed on breastfeeding. Two participants actively influenced his spouse in the workshop about breastfeeding. He said as follow:

“In fact, we ended up having a good decision after a bit of fight because I said that I would like having more consultation and information about breastfeeding. Finally… I let her know how important it was to me.” (P11)

Giving of precedence to the mother's choices

Most of participants thought that there was no point in contradicting with the mother's will or attempting to change her mind about the feeding method for the child. They prefer to refrain from commenting when the mother decided, for example switch the feeding with formula; instead, they respected and supported the mother's decision. The following statement was example statement from two out of 12 participants:

“It's her. It's not me. It's her body. I can't tell her what to do with it. I can't twist her arm to get her to stop breastfeeding or to start doing it against she will.” (P2, P5)

This finding in line with previous study that reported about paternal involvement is an important indicator of breastfeeding initiation and continuation. The study by Earle explored women's experiences and perceptions of breastfeeding. Infant feeding decisions seem to be made prior to conception or early in the pregnancy, and they are made irrespective of contact with health care professionals. ²⁷

Findings also indicate that, although the participants had knowledge of the benefits of breastfeeding, this did not influence their decisions. One of the most significant factors influencing the decision to breastfeed was the desire for paternal involvement. In both of Earle's studies, women wanted to involve their husband in baby care both to provide relief from the “daily routinary activity” of early motherhood as well as to share the experience of parenting. ^27,28 Earle concluded that men should be included in breastfeeding promotion campaigns. ²⁸

Theme 3. Experience of the husband and the family in supporting breastfeeding

This theme was supported by three categories namely: (a) finding of information and resources for the mother, (b) reinforcement and encouragement for the mother, and (c) financial support and help with the daily activities of the mother.

Finding of information and resources for the mother

All participant stated that they tried to get more information about breastfeeding. For example the statement from four out of 12 participants as follow:

“We share information about breastfeeding. Sometimes, I also give my wife some interesting articles about babies and breastfeeding from the internet or newspapers.” (P1, P5)

“Sometimes, I ask questions and discuss with friends who have many children, as they are more experienced.” (P6)

“Usually, I get information about breastfeeding from my mother. I trust her because she has many children, and all of them are healthy and successful.” (P7)

Most participants believed that they need more information about pregnancy, childbirth, breastfeeding, and parenting. Four out of 12 participants stated the following statement:

“Provide information about why breastfeeding is best for the baby and the mother.” (P2, P6, P8, P12)

Reinforcement and encouragement for the mother

All participants said that they always try to give reinforcement and encouragement to their wife to breast feed their baby. For example, the statement from six out of 12 participants as follow:

“My wife's mood is very important. If she is happy, it will affect her milk and my baby. If my wife tired and sad, her breastmilk usually obstructed.” (P1, P3, P5, P7).

“I give her strengthening and more attention, such as by talking more, walking together in nearby park, giving her massages, and telling her that our baby is as beautiful as her mother.” (P2, P6).

Emotional support and acknowledgment of the mother's effort in breastfeeding are particularly important. Mothers talk about the difficulties of the first few weeks at home with a newborn and how important is the support from their partners in encouraging and understanding of the time required during breastfeed. Participants said that they would give positive reinforcement to their wife. Here is the example of statement from three out of 12 participants.

“Just that encouragement. You know, when you say to your wife, ‘You did a good job in those early days, when you were feeding for 40 minutes or an hour.’ She found that really helpful.” (P5, P11, P12).

According to two participants, the confidence of their partners increased when they know that their husband trust to do the best for their children.

“She likes that I trust her to do what is best for the baby.” (P2, P10)

Financial support and help with the daily activities of the mother

Some participants helped their partners in the different ways. These included assisting with meal preparation, housework (such as dishwashing and laundry), and shopping; bathing the baby; bringing the child to the mother for nighttime feeding; and doing things to help the mother relax (such as neck massages), and emotional support. For example, the statement from six out of 12 participants as follow:

“I want to give her a lot of money…” (P6, P8)

“Sometimes, I help her finish the housework. I take care of the children to give my wife a chance to take a break, especially during holidays and weekends.” (P1, P4, P5, P11)

The findings from this study highlight the importance of practical, emotional, and physical support for mothers who breastfeed. This finding in line with another research finding that many women encounter difficulties in breastfeeding and need the support of their partners to be successful. The importance of breastfeeding support was identified from the fathers in this study. Providing more information about the benefits of breastfeeding will help both the mother and her baby.^29,30

Another similar research among the women support group also found that women comment frequently and positively about the breastfeeding support they receive from other breastfeeding mothers. ³⁰ Mothers find it favorable that women in support groups have experience in breastfeeding and are knowledgeable, reassuring, nonjudgmental, and prepared to listen. Their husbands were able to get benefit of this learning when their wives share the information.

Theme 4. Women's lack of knowledge, inconvenience due pain as the most impending factors of exclusive breastfeeding

There are five categories supported this theme namely: (a) breastfeeding difficulties caused by the mother's pain and inconvenience, (b) mother's lack of knowledge about the correct breastfeeding position after surgery, (c) perception about low of breast milk production in the post-cesarean- delivery period, (d) cultural factors, and (e) paternity leave.

Breastfeeding difficulties are caused by the mother's pain and inconvenience

All participants mention that the breastfeeding challenges experienced by post-cesarean-section mothers were their pain and inconvenience. For example, the statements of four out of 12 participants.

“My spouse finds it very difficult to breastfeed after cesarean section. This is because they complain that they still feel pain and inconvenience.” (P2, P3, P4, P6)

Mother's lack of knowledge about the correct breastfeeding position after surgery

Three out of the 12 participants stated the following.

“She said that she did not know the best breastfeeding position for mothers after a cesarean section. She was confused because she can sit well after surgery, and there was a postoperative wound. She was afraid that the baby would touch the wound.” (P4, P6, P8).

Perception about low breast milk production in early postcesarean- delivery period

Most of participants stated that their women felt after cesarean operation the production of breast milk become low. Four out of 12 participants stated as follow:

“Mother felt her breast milk low flow, and our baby had to suck hard to get milk but they didn't get enough. Nevertheless, a breastfeeding mother who receives support and consumes a balanced nutritious meal will have enough supply of milk. However, some problems will encounter such as lack of support, the secretion of milk fluctuates, and she complains of breast pain, then the formula becomes an alternative.” (P3, P6, P7, P8)

Cultural factors

All participants agreed that some family and community beliefs and values influence mothers’ breastfeeding experience. There are two subcategories supported the cultural factor.

“Mapas” belief in some areas. All participants that live in Cibinong area stated that they have to follow the traditional belief from their family that called” Mapas” is belief that the post-partum women prohibit to eat a certain food and not allow to do outside house activities until 40 th day after delivery. The two participants explained as follow:

“In our society, we know that there is a culture of ‘mapas’: from the baby's birth until their 40th day, the mother is not allowed to eat certain food and do other activities, such as showering in the rain. If this period passes and the mom may eat whatever they want and can do outside home activities.” (P4, P6)

Pre-lactation food, such as chewed dates and honey as a breastmilk alternative. Some participants stated that their parents advised them to give their baby a chewed dates (mother will chew the dates before they give to the baby) and honey as breastmilk alternative. Two out of 12 participants stated as follow:

“Our parents suggested that, if the mother's milk will not come out, we should put chewed dates on the child's palate to keep the baby from starving.” (P3).

“When the baby turns a month old, they usually start to become fussy. We give rice [starch] water so that the baby becomes calmer and gains weight increase quickly. We gave our baby honey water to help the baby had become bigger and stronger…” (P5)

Paternity leave

Some of participants stated that paternity leave could help to support them in their involvement in maternal and childcare. Here are some statements from three out of 12 participants.

“The leave given by the company when my wife gave birth seemed insufficient; it was only three days. It would have been very helpful if it were longer leave. I could accompany and help my wife in the days she was adapting to her new role and providing enough mother's milk in the early post-cesarean-section period.” (P2, P5, P6)

Difficulties have been reported by studies on women's breastfeeding experience, including infants’ poor latching, which results in pain.³¹ Exclusive breastfeeding in post-cesarean-section mothers remains low, and this is in line with research conducted by Ahluwalia²² which stated that mothers who breastfeed after cesarean delivery tend not to breastfeed exclusively. This is also supported by research conducted by Evans and Chertok which concluded that mothers who deliver via cesarean section are three times more likely to stop breastfeeding in the first month postpartum.¹³ This is due to the absence of early breastfeeding initiation and delay in breastfeeding compared with mothers who give birth normally. The problems encounter among mothers to do exclusive breastfeeding in this study is mostly due to social and cultural factors.⁷ This finding different with another study that found the most common reason for a mother not to exclusively breastfeed is insufficiency in their breast milk.

Obstacles to do breastfeeding in the first day after cesarean section delivery are prominent and should be taken account of concern to health workers and the husbands. This is in line with research conducted by Lin, she found that mothers express their desire to be assisted by health workers when they first breastfeed.²⁹

The participants in the current study considered their partners’ pain to be a hard part of breastfeeding. Two of the participants in the current study remarked that their wives encountered both physical and emotional pain during breastfeeding. In line with this finding, research by Okon found that fathers described issues and difficulties pertaining to the breast and breastfeeding, including nipple soreness.³²

Although knowledge about exclusive breastfeeding were good enough, especially among the mothers and grandmothers, exclusive breastfeeding was not always practiced. The husbands did not know as much as their wives and grandmothers about exclusive breastfeeding. The last campaigns about the importance of exclusive breastfeeding may have led to this high level of awareness, but they were not successful in helping the women practice the desired behaviors. This finding in line with that of a study performed in Cambodia.³³

This study highlights the barriers to exclusive breastfeeding including culture and belief of the family. While almost all the women in this work understood the benefit of exclusive breastfeeding, but husbands and their parents did not promote it and introduced solid food and liquids before their children were 6 months old. This practice was mainly driven by the belief that certain foods and liquids, such as dates, honey, and rice water, are important for the health and development of babies. Educational campaigns should emphasize that breast milk can provide complete nutrition for babies, particularly within the first 6 months.³⁴

Educating the public about the benefits of breastfeeding and its contribution to the health of children should be continued in order to promote positive attitudes toward breastfeeding.

Conclusions

This study provides important insights about fathers’ experiences in supporting their spouse to give the breast feeding after section cesarean. Husbands’ support can help their partners in exclusive breastfeeding, improve her motivation, and solve some obstacles regarding some beliefs and values in their families (particularly grandparents) and communities. Nurses and lactation consultants must address fathers as significant participants in the breastfeeding process. They should be included in breastfeeding education and the support sessions that are offered to mothers.

Footnotes

Institutions where the research was carried out: This study was carried out in selected social workers and midwives’ houses in Cibinong West Java Indonesia.

Funding: This study was supported by PUTI Doktor 2020 initiated by the Directorate of Research and Community Engagement, Universitas Indonesia No. NKB-3211/UN2.RST/HKP.05.00/2020 and supported by LPDP.

Contributions: TB, participated in the data collection and analysis and drafted the manuscript. SW, TB, participated in data collection and analysis, drafted manuscript; SS, made substantial contributionsto conception and design, revising manuscript for intellectual content, acquisition of data analysis and interpretation, final manuscript approval; SA, substantial contribution to conception, acquisition of data analysis and interpretation, involved in manuscript revision; JG, substantial contributions to conception and design, acquisition of data analysis and intepretation, involved in manuscript revision. All authors read and approved the final manuscript.

The authors declare no potential conflict of interest.

Availability of data and materials: The data used to support the findings of this study are available from the corresponding author upon request.

Ethical approval: Permission to conduct the study was obtained from the Faculty of Nursing Ethics Committee, Universitas Indonesia (no. 296/UN2.F12.D/HKP.02.04/2018)

Patient consent for publication: Prior to the study, all patients had signed an informed consent, which explained that the results of this study could be used in the form of reports, presentations, and publications, but the researcher would not identify the patient's personal data. Anonymity and confidentially were maintained. Participants will be provided feedback on the findings.

Informed consent: After ethical consideration. In addition, written consent was taken from the participants. The consent form was developed in bahasa. Voluntary participation was encouraged, and the participants were assured that their withdrawal from the study would not be penalized. For respondent who participated in the research, fill out their informed consent form after they were provided with complete descriptions of the aims and procedures of the study, were made aware of data protection, and were ensured they could terminate the study at any time.

Conference presentation: This final manuscript has been presented at 7^th Virtual Biennial International Nursing Conference, Faculty of Nursing, Universitas Indonesia on September 24^th, October 30^th, November 16^th 2020.

Acknowledgements

The authors are grateful to all the study participants, social workers, midwives, and nurses, for granting us the permission to undertake this study.

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Fathers’ Role in Sustainability of Exclusive Breastfeeding Practice in Post-Cesarean-Section Mothers

Abstract

Background

Design and Methods

Results

Conclusion

Keywords

Introduction

Design and Methods

Results

Discussion

Theme 1. Knowledge about exclusive breastfeeding

Knowledge of the advantages of breastfeeding

Risk of formula

Low cost and high efficiency of breastfeeding

Theme 2. The Role of Fathers in Breastfeeding

Responsibility for families ‘functions

Partnership in decision making and spending time with their baby

Giving of precedence to the mother's choices

Theme 3. Experience of the husband and the family in supporting breastfeeding

Finding of information and resources for the mother

Reinforcement and encouragement for the mother

Financial support and help with the daily activities of the mother

Theme 4. Women's lack of knowledge, inconvenience due pain as the most impending factors of exclusive breastfeeding

Breastfeeding difficulties are caused by the mother's pain and inconvenience

Mother's lack of knowledge about the correct breastfeeding position after surgery

Perception about low breast milk production in early postcesarean- delivery period

Cultural factors

Paternity leave

Conclusions

Footnotes

Acknowledgements

References