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

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)

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

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.

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 Ahluwalia ²² 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.