Influence of the social network on the breastfeeding process : a phenomenological study

Objective: The aim of this study was to understand the influence of women's social network during the breastfeeding process. Methods: Qualitative research was conducted, based on Alfred Schütz's phenomenological sociology framework and Sanicola's social network approach, at a primary health care unit in Monza Italy. Eleven women were interviewed using semi-structured interviews. Results: Three categories were found through comprehensive analysis: routine family support, professional counseling to overcome difficulties and understanding and support perspective. Social network members who had the highest influence on the decision to breastfeed and to maintain it were: husbands, participants' mothers, friends and nurses. The relationship with these members meant assistance, counseling and expectations for understanding and support. Conclusion: Knowledge of the social network of these women is an important resource for health professionals to seek interaction and strengthening of this network as well as to provide more effective actions for breastfeeding promotion, protection and support.


INTRODUCTION
The World Health Organization (WHO) advocates that maternal milk should be offered as the only nutrient source for children until six months of age.However, it is possible to notice that non-successful breastfeeding experiences or early weaning are present in various societies [1][2][3] .Early weaning is understood as the introduction of any type of complementary food to the diet of babies who, until then, were exclusively breastfed, before six months of age 1,2 .
In 2013, according to the WHO 3 , the percentage of children who were exclusively breastfed between zero and six months of age was 36%.This situation is even more critical in European countries, where, in the period of 2006 to 2012, only 25% of children were breastfed in the first six months of life.The WHO report showed that, in 21 European countries, an average of 13% of children were breastfed during the first six months of life, evidencing percentages that were considerably below international recommendations 4 .
In Italy, an investigation conducted by the Italian Society of Pediatrics in 2015 revealed that, after delivery, 90% of women exclusively breastfed their children.However, at hospital discharge, that percentage dropped to 77%.At four months, 31% of women continued with exclusive breastfeeding and, six months after delivery, only 10% of them were still exclusively breastfeeding.Some possible causes for early weaning that were mentioned were socioeconomic and geographical differences, which are barriers for women to receive quality health care and be monitored during the breastfeeding process 5 .
In Brazil, starting in the 90s, some studies on breastfeeding demonstrated the importance of considering women capable of choices, of having certain sensibilities, histories, daily routines and as individuals who need somebody at their side for support and care [6][7][8][9] .
In this perspective, it is necessary to consider both biological and social aspects of breastfeeding in order to understand the conditional factors of this practice.
There is vast literature addressing the biological phenomena that interfere in the practice of breastfeeding because concepts such as the ones below were predominant for years: "breastfeeding is natural", "all mothers have milk", "breast milk has everything your child needs", "it protects against infections" and so on.However, after countless educational campaigns for the promotion of breastfeeding, a question remains: why do some mothers have problems with exclusive breastfeeding, even when they know all advantages of breast milk for children 2,5,9,10 ?
This question reveals that, in practice, breastfeeding is not instinctive nor automatic, it is an action based on subjectivity and on women's experience, being defined by the relationships established with members of their social networks.
Social network is understood as "a set of interpersonal relationships that determine an individual's characteristics, such as: habits, customs, beliefs and values", with individuals possibly receiving emotional, material, service and information support from this network 11 .Social networks can be primary or secondary.In primary networks, ties are defined by relationships of family, friendship or neighborhood.Secondary networks can be defined by relationships with institutions (health, educational, and social care institutions, among others), organizations in the third sector or with places in which individuals work 11 .
In analyzing international literature, a knowledge gap was found in the theoretical methodological approach to social networks of Italian women who experience breastfeeding, since most studies are quantitative and point to aspects related to advantages of maternal breastfeeding for children and mothers, length of breastfeeding, biological value of breast milk, myths and maternal knowledge 5,12,13 .
Thus, most studies focused on the theme of breastfeeding pointed to the biological aspects that are part of its practice 1,10,14 .To complement that, qualitative studies on social conditions, such as the influence of social support or social network on breastfeeding, as well as studies with a phenomenological approach, enhance the understanding of the breastfeeding phenomenon [6][7][8] .
As such, the aim of this study was to understand the influence of women's social network during the breastfeeding process.

METHODS
This is qualitative study was conducted during a postdoctoral internship at Corso di Laurea in Ostetricia of Università degli Studi di Milano-Bicocca, in Monza, Italy.
In this study, Sanicola's theoretical-methodological approach for social networks was adopted 11 , as well as Alfred Schutz's phenomenological sociology 15 .These frameworks enabled the identification of social networks, as well as the understanding of intentions that permeated the women's actions when interacting with members of their networks during the breastfeeding process.
According to Schütz 15 , humans are social beings, who live in a world shared with their equals, with things and with themselves.In this relation, humans express themselves through their biographical situation, which corresponds to the sedimentation of all their prior experiences and the knowledge reserves at their disposal, which will set them into action.
Schütz defines action as intentionally projected human behavior.When projecting an action, the individual anticipates a behavior -expresses a purpose -when the possibilities of doing it are directly linked to the elements of present life 15 .
In this perspective, with the goal of understanding the individuals' subjective action, Schütz 15 emphasized the importance of learning the reasons that cause a specific behavior ou conduct.For such, he considered "reasons for" whatever was defined as something that one wishes to accomplish, objectives one tries to reach, that represent a time structure aimed at the future, constituting a projected act, in other words, the imagined state of things to be accomplished by future actions.And as reasons-why, reasons evidenced by finished events, which have a time direction pointing to the past 15 .

Influence of the social network on breastfeeding
Souza MHN, Nespoli A, Zeitoune RCG Based on these concepts, it was found that the phenomenology approach is a path for the comprehension of the meaning of social relations experienced by breastfeeding mothers, since the breastfeeding practice is a social action permeated by motivations, reasons and subjectivities.
Eleven mothers of children under six months of age participated in the study.Research inclusion criteria were: women aged above 18 years, who delivered after the 37 th week of pregnancy, breastfed their children, accepted to participate in the study and signed a free and informed consent form.Mothers of children who needed to be admitted to intensive care units and those who presented diseases that prevented breastfeeding were excluded.
The data gathering instrument comprised sociodemographic data and the following guiding questions for the phenomenological interview: "Who are the people present in your life?; Have you ever needed help, or had some difficulty in breastfeeding the child?; Who did you rely upon?; Why did you rely upon these people?; and What do you aim for or what do you expect when interacting with them?" Data were collected at a primary health unit in Monza, Italy, during four Thursdays of March 2010, when there were pediatric nursing appointments for children from zero to six months of age.After the appointments, the women were invited to participate in the study and the interviews were conducted at a reserved room in the unit.
During the reports, participants mentioned people or families who were close to or distant from their family context, institutions they attended during the breastfeeding period and the types of ties they had with members of their social networks, as proposed by Sanicola 11 .
Interviews stopped at the 11 th respondent, when ideas began reappearing in speeches, when it was possible to learn typical actions of women who had children under six months of age and with experience with breastfeeding in the researched context.
After the interviews, testimonials were transcribed and translated to Portuguese.To ensure participant anonymity, speeches were identified with the letter M followed by an Arabic number corresponding to the order of the interview.
For testimonial analysis, the following steps were adopted: Attentive and careful reading of testimonials, which were transcribed in full with the aim of learning about deliberate and motivated actions of women who participated in the study; grouping of speech excerpts that expressed common ideas related to the women's actions when interacting with members of their primary or secondary networks and; understanding of typical women's actions through comprehensive analysis 16 .
The study followed ethical parameters and was approved by the Research and Ethics Committee of Ospedale San Gerardo and Università degli Studi di Milano-Bicocca, di Monza, Italy, under protocol No. 2/4 Verbale della reunione del Senato Accademico de 02/08/2010, according to procedures for observational studies with human subjects.

RESULTS AND DISCUSSION
The respondents' age group varied between 27 and 40 years, with six of them being over 35 years old.Ten participants had been pregnant for the first time, lived with their husbands and worked outside their homes.Eight received prenatal care.Regarding infants' age: six were under three months old and five were between four and six months old.Regarding exclusive breastfeeding length: four participants breastfed for less than one month, three did it for two to five months and four were exclusively breastfeeding their children, who were in the first trimester of life.
When questioned about the configuration of their social networks, respondents mentioned the presence of the following members: mother, father, husband, child, siblings, grandparents, uncles and aunts, sister-in-law, mother-in-law, neighbors, friends, colleagues and health workers at the maternity hospital and at the primary health care unit.However, most women remarked that, during the breastfeeding phase, the most present members of their social networks were: husband, mother, friend and nurse of the primary health unit.
Results showed that breastfeeding women, in their own world, belong to a relational context.In this world, individuals' actions are always aimed at somebody, they do not live alone, but in relationships with other people, face to face relationships, I-you relationships, I-we relationships 17 .
In fact, family members come first as a reference for women who experience breastfeeding.During this phase, due to their proximity to primary social networks, they can share knowledge, experiences, habits and conducts 18 .
In agreement with this research's results, a study conducted at a community in Rio de Janeiro, Brazil, also demonstrated that women in the breastfeeding phase presented strong ties to their primary social networks, which comprised: mother, partner, friends and neighbors.That research also demonstrated the importance of a relationship of familiarity with social network members in order to ensure successful breastfeeding and increase in its length 7 .
Identification of respondent's social networks enabled a global view of their relationship context, as well as the understanding of the influence of these relationships on the breastfeeding process, evidencing these women's typical actions.
For Schutz, typification refers to an invariable representation of an individual's actions or the actions of a social group that experience a similar situation, which makes them homogeneous, removing their individual characteristics.Therefore, learning typical actions enables anonymous and objective analysis of a researched phenomenon, which will unfold from subjective and intersubjective experiences 15 .
In this perspective, three categories emerged from the comprehensive analysis of reports, with two related to reason why: routine family support and professional counseling to overcome difficulties, and one related to reason for: understanding and support perspective.This last category was found after responses to the question: "What do you aim for or what do you expect Influence of the social network on breastfeeding Souza MHN, Nespoli A, Zeitoune RCG when you interact with (person mentioned in social network description)?",going back to typical actions of women during the breastfeeding period.

Routine family support
The study participants could count on family support when going through breastfeeding.Families offered company, child care help and support in chores, as can be learned from these excerpts: [...]She used to keep me company.She (sister-in-law) stayed with me in the mornings (M4).

[...] She (mother) comes in the afternoon. She keeps me company, helps me and helps me with the baby (M7). [...] My husband helps me at home, when he arrives, because he works. He is the one who cooks. (M6)
My mother was here with us in the first week.Then she went away and my mother-in-law came.Then my mother came back ... My husband is very attentive, he has been supporting me a lot.(...)He took vacations to stay with me (M10).

[...] at home, my husband helped me with the other stuff while I breastfed (M11).
These speeches go back to the Reasons why present in the participants' relationships with their families, who are part of their primary networks.Such reasons are only accessible when action becomes a past act, in other words, when it has already been performed 15 .
Similar results were also found in national and international studies on the theme of social support for breastfeeding women, evidencing the importance of family support, especially in the early stages of breastfeeding.These studies point to the fact that for mothers to breastfeed successfully, it is not enough to just choose to practice it, they must be part of a social context that helps them to take this decision forward 6,7,9,12,18 .
The fact that most researched women mentioned that, in addition to their husbands, they also counted on their mothers, mothers-in-law, sisters-in-law or friends evidences the predominance of feminine figures at their sides.
The influence of feminine figures on supporting breastfeeding reinforces the idea that the female gender entitles women as trusted caregivers, given that they are almost always mothers, who have experience with maternity and breastfeeding 6,7,19 .

Professional counseling to overcome difficulties
The second category related to reason why, entitled "professional counseling to overcome difficulties" was expressed by the following speech excerpt: [...] Breastfeeding time was dramatic.She did not latch on, I had little milk...She (nurse) gave me many advices, of which I tried every single one and found that almost all of them worked (M4).

I went to the hospital for counseling [...] to understand that what I go through, maybe other ones also go through (M10).
[...] in the beginning, I did not want to breastfeed because my breast was sore [...] I came here (to the health unit) when I was going through a bit of a crisis ... I feel well here.If I have problems, I make questions and receive support (M8).
[...] he did not latch on.By luck, I had a nurse that gave me advices and helped me, because I had cracking and my nipple was big, which made him dry heave.[...] Then I had mastitis and she told me what to do.The advice she gave me helped me.[...] Before, I used to think that difficulties were for just some people, I did not use to think that I had to pay attention.I found myself with difficulties, but the nurse helped me (M9).
Concerning the presence of members of the secondary network, comprising especially health workers, it was found that nurses were mentioned as the ones most involved with the women during the breastfeeding process.In agreement with other studies, it was revealed that the secondary network is an important support for breastfeeding women, mainly when difficulties happen 6,7,9,18,20 .
In this sense, the importance of care offered by health workers to women during the breastfeeding period is emphasized, as well as the recognition of their social networks, which makes it possible for them to feel treasured, aware of belonging, leading them to face the main problems of the breastfeeding phase and to avoid isolation and anonymity [7][8][9][10][11][12][13][14][15][16][17][18][19][20] .

Understanding and support perspective
When searching for reasons for that expressed the intention of women during the breastfeeding process, in other words, what they expected when interacting with their primary and secondary social networks, the category understanding and support perspective emerged.This is expressed in the following speeches: [...] I expect to keep coming here, to be understood and supported.(...) In the beginning, I thought I wouldn't be able to breastfeed.[...] However, thanks to L (nurse), who followed my case for so long, I was able to breastfeed.(M5) [...]  During the breastfeeding phase, women mentioned the expectation of being understood and supported by members of their social networks and emphasized the intention of keeping relationships as positive aspects to overcome difficulties and successfully breastfeed.
Women who breastfeed are unique persons, who have ontological demands when breastfeeding, such as the need to be understood and to have relationships with other individuals, establishing I-you face-to-face relationships 15 .
According to some studies, it is relevant that interpersonal relationships among mothers, families and health workers, through experience exchange, be taken into consideration when planning and establishing actions for breastfeeding promotion 7,12,13,20 .Thus, in care practice, workers must favor verbal expression of desires, expectations and difficulties, which are part of an experience that, many times, is new, enabling a more effective intervention, according to the unique characteristics and daily routines of each woman 16,17,[19][20][21] .
The categories, resulting from the aims of the subjective actions of women who established relationships with their relatives, friends and health workers during breastfeeding, made it possible to learn about reasons and intentions, as well as their typical actions.Thus, from the comprehensive analysis of reasons for, it was possible to learn that the typical action of women experiencing breastfeeding in the first six months of their children's lives, when interacting with their social networks, includes expectations related to the need to be able to rely upon family members and workers who understand them and provide support in face of difficulties with breastfeeding.

CONCLUSION
This study made it possible to understand, through the women's life experiences, that breastfeeding involves many reasons and intentions.It does not depend on the knowledge of advantages and techniques or prior decisions.
During the phenomenological interview, it was possible to conclude that this phase received meaning from them.Because they were observed in their uniqueness, the women felt free to speak about their lives and relationships, letting themselves be seen as subjects and protagonists of their own stories in a context in which breastfeeding involves more factors than just giving their milk to their children.
Thus, understanding relationships that are established between breastfeeding women and members of their social networks implies opening oneself to a reality that transcends biological aspects involved in the breastfeeding process, which is not limited to classic counseling about the advantages of breastfeeding, but that is permeated by meanings and intentions.In this context, the presence of another person can be helpful during the period in which women are breastfeeding.
In their daily routine, women had support from members of the primary network, who helped them with domestic chores and child care.When they needed, they sought the secondary network for professional health counseling on how to solve breastfeeding problems.Expectations for understanding and support were the typical actions for the women during the breastfeeding phase.This study's results are limited because data were gathered at a specific time of the month and at a single primary health care unit of the city of Monza, Italy.Perhaps the inclusion of other units would allow the authors to conduct generalizations or capture other typical factors of actions of women who experience breastfeeding in the Italian context.
Nonetheless, the use of Alfred Schütz's phenomenological sociology as reference and the social network approach in researching women who experience the breastfeeding phenomenon enabled the understanding of the influence of these women's relational context and represented an important resource for the work of multi-professional teams, regarding the planning of actions focused on the promotion, protection and support for breastfeeding, as well as for strengthening the social networks of breastfeeding women.