Nutrition during early stages of life affects growth and represents a risk factor for future chronic diseases. These stages include the so-called “first 1000 days” or window of opportunity for nutritional interventions ranging from conception to the first 2 years of life  .
During breastfeeding, especially if it is exclusive, mother and son interlace their present and future health. The components of human breast milk provide the nursing baby with signs about the environment from an immunological and nutritional point of view. Milk production and composition are affected by three aspects of the mother’s nutrition: regular eating, nutrient and energy reserves and the use of nutrients influenced by hormonal environment. Breastfeeding increases women’s nutritional needs, since their own nutrition affects milk quality and the feeding of the nursing baby, impacting on their own nutritional status and the future pregnancies they may have   .
Health policies in Argentina aimed at promoting breastfeeding for its short and long-term benefits lead to satisfactory results, since 95% of women are breastfeeding when discharged from hospital and 53% are able to keep exclusively breastfeeding up to the 6th month   . However, there is no information published to characterize the mother’s diet and/or nutritional status during breastfeeding  .
Identifying and describing breastfeeding mothers’ social representations during this period related with the following areas:
・ Importance given to self-care in relation to the diet, identifying the determining factors for healthy habits and coping strategies.
・ Connotations referred to food products, drinks and supplements.
・ Body image and post-partum weight retention.
・ Commonly consulted information sources.
3. Materials and Methods
In-depth interviews were carried out having the following inclusion criteria: healthy women, over 18 years old within the first 6 months post-partum on exclusive breastfeeding or, if infant formulas are included, less than two bottles a day are given. Women on a special diet for a pre-existing condition (e.g. diabetes, celiac disease, high blood pressure, dyslipidemia, metabolic syndrome) or having a disease or medical condition which, based on the Investigator’s judgment, could impact on the interview, were excluded. Sampling was intentionally carried out through a voluntary invitation and an announcement posted on FUNDALAM’s (Fundación de Lactancia y Maternidad [Breastfeeding and Motherhood Foundation]) website from April to June 2015. Women were contacted for enrolment by e-mail. Data collection had been carried out in June 2015 and ended when the knowledge saturation criterion was fulfilled, i.e., when the inclusion of new interviews did not bring about an automatically new understanding. The Protocol had been approved by an Independent Ethics Committee. All participants signed the Informed Consent before the interview.
Semi-structured interviews included the following topics:
・ Self-care: Exploration of health concept, self-care strategies for one’s own and baby’s health, perceived barriers and benefits.
・ Diet: Exploration of habits and changes in diet and their link with breastfeeding (Food, drinks, supplements).
・ Weight: Exploration of representations, beliefs, values in relation to weight increase/body image during pregnancy and its relationship with breastfeeding.
・ Information sources: Exploration of sources of information about mother’s care during breastfeeding, references, family influence and health care professional’s role.
The guide explored the main constitutional categories of the Health Beliefs Model (Becker and Maiman Version, 1975), PRECEDE Model (Green, Kreuter, Deeds, 1991) and Health Promotion Model (Pender N, 2011)    .
The Investigator introduced himself as a member of the health team and conducted the interview at the women’s home or work address. Interviews were anonymized, recorded in digital audio and transcribed into text using F4 Software.
Data analysis was carried out through qualitative techniques using Atlas ti 7.O. Software, following the coding grounds of the Grounded Theory from Anselm Strauss (open and selective coding) aimed at identifying emerging conceptual models   . Table 1 shows the topics explored.
Ten mothers living in the City of Buenos Aires were interviewed (Table 2). Among them, 4 were primiparous and 9 referred they were feeding their baby through exclusive breastfeeding. Mean age was 32.7 years old. In total, 90% of them achieved a higher education level (tertiary and university) and 60% were in their maternity leave.
4.1. Self-Care and Value of a Healthy Diet
Most mothers believe that a “healthy” diet is beneficial for breastfeeding, especially for the baby. They referred they had made dietary and health care changes since they got pregnant based on recommendations from health professionals (obstetricians), on their own (based on considering an aim: baby’s health and
Table 1. Analysis categories according to each adherence model and categories emerging from grounded theory.
Table 2. Characteristics of mothers (n: 10).
breastfeeding) or due to difficulties encountered with the pregnancy. However, they explained they had difficulties keeping the changes made during the pregnancy after the baby was born, because they forgot about self-care and prioritized behaviors beneficial for the baby or based on their partners’ or children’s eating preferences, not paying attention to their own diet, consequently disorganizing the eating habits and the family.
Main changes referred included not smoking, and not drinking alcohol since getting pregnant and, in terms of diet, they referred an increase in the consumption of dairy products, fruits, vegetables, water or juices, highlighting the decrease in the consumption of sodas and caffeine. They pointed out the importance of eating four meals, especially breakfast, and the value of food safety.
Women stated they “eat poorly”, “do not eat”, “eat little”, “snack here and there”, “eat whatever they find” and they could not even remember what they had eaten due to lack of time and family disorganization. They referred feeling ineffective, frustrated and stressed because they cannot put into practice the eating habits they believe are appropriate for breastfeeding, mainly in primiparous women, due to lack of experience.
Regarding commensality, women referred they tried to create shared spaces with their partners, but they found it difficult because they prioritized the demands from the baby, especially during the first month post-partum and among primiparous women. Dinner was the most valuable time to gather the whole family. Having other children helped respect commensality and organize the eating habits. The value given to breastfeeding made these women acquire skills to avoid interrupting it, thus adapting the family table around the baby’s schedule.
The perception of the mother’s “self-effectiveness” depended on several conditioning factors, such as coping strategies, family conditions, previous knowledge, grocery shopping habits, willpower and professional guidance. Among the strategies used, they referred family help, meal planning, frozen meal preparation, husband in charge of grocery shopping, prepared meals and home delivery (mainly in women having a high socioeconomic status) or shopping at community markets (Table 3).
Table 3. Verbatim phrases regarding self-care and value of a healthy diet during breastfeeding.
4.2. Connotations Referred to Food Products, Drinks and Supplements
Women interpreted thirst and hunger as a body need to produce breast milk, to make up for the low weight gain during pregnancy or due to anxiety. Therefore, mothers referred they were eating more food products and drinking more water.
Fruits and vegetables in general have a positive connotation. Cow milk showed opposing views: some of them were drinking more milk while others associated it with negative effects related with their beliefs and ended up avoiding it.
Certain food products considered less healthy were avoided, such as sweets, junk food, sodas, cookies, spices, coffee, mate (to a lesser extent) and alcohol. Reducing the consumption of red meat was found healthy, but they recognized they need to eat it.
Other food products avoided due to potential harmful effects in the baby, the breast milk or the mother included sodas, broccoli, eggplant, tomato, sauces, spices and fish. The women interviewed referred that such food products may impact on milk’s taste, quantity or quality (“creamy”; “watery”; “filling”; “they decrease the production”) and they may cause discomforts in the baby, such as feeling colicky, sleepy, gassy or constipated.
On the other hand, pasta and rice are replaced by fruits, jellies and juices, based on their association with maternal discomfort (“food poisoning”, “heartburn”, “they are heavy to digest”, constipation and post-partum hemorrhoids if they had a C-section).
In general, mothers stated they usually stop eating a specific food product if they relate its consumption to the appearance of some discomfort in them, followed by discomfort in their baby.
They also talked about the consumption of food products having personally valued positive properties such as coconut oil, fish, seeds, almonds and raisins.
When a woman is breastfeeding, supplements are less often prescribed. Faced with this situation, women took two different stands: a group stated they did not use them if supplements had not been prescribed to them, and even rejected them because they considered they were “not natural”. On the other hand, the other group stated they personally wanted to use them to combat tiredness. They referred a disparate consumption of supplements (iron, folic acid, calcium, vitamins) during pregnancy (Table 4).
4.3. Body Image and Post-Partum Weight Retention
There is lack of knowledge on what should be an appropriate weight gain during pregnancy. It is worth noting that mothers consider an 8 or 9-kilogram gain as a target accomplished, affected by their own aesthetical considerations and a positive assessment of their pairs. Overweight and absent tone are stated as the reasons for being unhappy with their own image, especially in primiparous women or those who performed sport activities before they got pregnant. Despite this,
Table 4. Verbatim phrases about connotations referred to food products, drinks and supplements.
they were waiting to complete the exclusive breastfeeding period to start focusing on coming back to their standard weight.
The association between breastfeeding and previous weight recovery was weak and doubted. The mothers who lost weight were the only ones who thought it was due to breastfeeding (Table 5). The factors identified as influencing in the weight decrease were, in the first place, physical activity, then, taking care of their eating habits and, lastly, breastfeeding.
4.4. Information Sources Consulted
The women interviewed stated they had not received or found information about eating and breastfeeding, acknowledging there is “lack of information” on the subject. Main references for consultation when having doubts or needing healthy guidelines were obstetricians during pregnancy and pediatricians during breastfeeding.
The nutritionist comes up as a possible reference, but none of the interviewed women actually scheduled a visit with one during pregnancy or breastfeeding. A limiting factor mentioned was “having to visit another professional, besides the ones already implied in pregnancy”.
The nursing consultants (“puericultoras”), especially since they offered home services, were valued because they provided emotional support, assistance and encouragement for a successful breastfeeding.
Doubts, crisis situations caused by the baby’s crying or pain, milk “coming in” or lack of professional advice made women resort to family members (in general, the baby’s grandmother) or friends as information sources. Since they had strong affective ties to those sources, professional advice usually ended up invalidated.
Some mothers stated they needed more information during pregnancy than
Table 5. Verbatim phrases about body image and post-partum weight retention: beliefs (knowledge) and attitudes.
during breastfeeding, because the latter is perceived as a “natural” time in which there is no need to learn from others (Table 6).
This study was aimed at identifying and describing conceptual models from women during the breastfeeding period in relation with the importance given to eating as a self-care measure; connotations referred to food products, drinks and supplements, post-partum weight retention and information sources consulted. Findings show that maternal eating comes up as a health conditioning factor since pregnancy.
During breastfeeding, there were conditioning barriers found for having healthy eating habits, mainly family disorganization, making food choice and commensality difficult. Breastfeeding was not directly associated with weight loss. Mothers were seen unsatisfactory with their own body, showing certain disregard for it during the first months, since the focus was placed on the baby. The information sources referred were diverse and, when faced with contradicting messages, the sources chosen were the ones with strong affective ties.
As seen in previous researches, mothers acknowledged the need to follow a special diet during the breastfeeding period. As a rule, healthy food products that should be included and foods considered prohibited were listed. A Brazilian study on social representations in breastfeeding mothers showed that “healthy” and/or “strong” food products were associated with a high content of iron and vitamins (fruits, vegetables, meats, rice and liquids) to avoid maternal weight loss, “to enrich” breast milk and benefit the baby. “Prohibited” or unhealthy food products included chocolate, ground pepper, some vegetables (cabbage, pepper), alcohol, coffee and cow milk  . As shown by the findings of this study, food products considered unhealthy were often cut out to protect milk production, avoid digestive discomfort or possible baby allergies, among other reason    . Vallianatos et al.  showed the need to “eat for two” as a cultural belief to assure there is enough milk production and well-being for the mother and the nursing baby. These ingrown beliefs, mostly having not enough scientific grounds, could lead to breastfeeding mothers having unbalanced eating practices  . Raman et al. highlight there is a high diversity observed when valuing food products and their restriction or consumption in a review on cultural practices and beliefs in perinatal nutrition, in low and middle-income countries.
Table 6. Verbatim phrases about the commonly consulted information sources, skills and interpersonal influences.
Food products valued as good or bad did not have major consensus among countries or even among close populations. The revision reaches the conclusion that dietary restrictions based on cultural reasons are ingrown and widely spread around Asia, Africa and some areas in Latin America  .
As shown by the findings of this study, publications made in different contexts highlighted that the knowledge about puerperal self-care is scarce, pointing out that the Health Team does not provide education on the subject and that the main information source in primary care was the midwife or cultural beliefs    .
The results of this study regarding the concern on body weight are aligned with a previous study conducted in Sweden, where mothers stated they did not know what the recommended weight gain during pregnancy was or the risks it could cause for the delivery and the weight retention afterwards  . Although there is a physiological mechanism that uses women’s fat reserves for milk synthesis, mothers did not consider breastfeeding to have a positive effect in post-partum weight loss. Evidence available in this field shows inconsistencies, although minor positive effects of breastfeeding in weight loss are observed    . This study did not show the practice of eating to obtain “well-being” or relief from the tiredness and pain, since appetite increase was interpreted as a biological effect of milk production  . Regarding body image dissatisfaction, a Chilean study also showed that most mothers (76%) referred negative changes in the body shape and breasts  .
The use of supplements was scarce and only based on the mother’s wish, in alignment with a Spanish study, which showed that only 22% of breastfeeding mothers use them  .
“Self-effectiveness” and the “value of a target” came up evidently in the use of coping strategies to deal with the barriers shown (stress, tiredness, disorganization and family needs). The higher the value the mother placed on breastfeeding for the baby’s health, the greater her motivation to continue breastfeeding. According to Cerda Muñoz L.  , the breastfeeding mother has a better development of self-esteem and self-confidence, since she can prove the ability only mothers have of feeding their children, satisfying their needs and creating the bonding. Several studies show that the intra- or extra-family social network provides the support needed for the mother to continue breastfeeding and for her own self-care   . On the other hand, to achieve better coping strategies, mothers demanded more attention from the health team, usually absent, since they focus exclusively on the newborn   .
A woman’s behavior, in terms of taking care of her own eating habits during the breastfeeding period is influenced by culture and social context, including beliefs, feelings, perceptions, values, motivation and attitudes, among other factors. This study identified and characterized beliefs and barriers for maternal eating with the aim of including the socio-cultural aspect both in the design of public health policies and in the contextualized individual dietary-nutritional approach. If tensions between social beliefs and messages from health professionals could be reduced, a higher compliance of recommendations could be attained.
The post-partum period, which can be considered an inter-gestational time, is an opportunity to provide health interventions, allowing the mother to feel emotionally supported so that she can continue with the changes made in her eating habits, if done so during pregnancy. Providing support when breastfeeding and the dietary-nutritional follow-up needed to make weight recovery easier and prevent overweight would allow her to face a new pregnancy having a higher level of knowledge, self-confidence and a better nutritional status. The perception of an increase in family complexity focusing on the newborn makes it relevant and needed to start educating since the pregnancy about self-care during the post-partum period. In the long run, perinatal interventions should be aimed at improving maternal nutrition and weight through a multidisciplinary approach, so as to reduce the potential of transgenerational transmission of obesity risks and other non-transmissible chronic diseases.
Finally, and based on the lack of local data, we recommend that quantitative studies are conducted to describe the characteristics of maternal eating during the breastfeeding period, focusing on the intake of critical nutrients and how the analyzed factors affect the actual eating habits during this period.