These study results corroborate the hypothesis of the relationship between FI in families of pregnant women and the low frequency of breastfeeding at birth. Associated with this outcome, other determinants, such as the consumption of alcoholic beverages during pregnancy, the occurrence of disease prior to the woman's pregnancy and respiratory diseases in newborns, were also significant in relation to the lower frequency of BF.
FI is defined as the lack or limited access to adequate quality food in sufficient quantity for families37. This measure has been reported as a good indicator of several negative health effects, among which a shorter breastfeeding duration is pointed out 38 or a reduced chance of breastfeeding in the first hour of life 39.
The study carried out in pregnant women at clinical risk reinforces the importance of investigating the FI indicator in this physiological period given that the proportion of mother-child pairs with FI was almost 60%, which was higher than that indicated in the last report of the Brazilian Household Budget Survey (2018)24 (36.7%) and lower than that in the Brazilian FI Survey in the context of the COVID-19 pandemic25. According to the high biopsychosocial vulnerability of this group, it is expected that the effects of FI are potentially harmful in this period for both the mother and the foetus/newborn.
The importance of this result is also demonstrated when considering the concept of food and nutrition security (FNS) adopted in Brazil, which encompasses numerous aspects of the food and nutrition process of individuals and emphasizes guaranteed access to sufficient quantity and adequate quality of food for all members of a family37, not just adults or children.
In this context, and considering that even in the new millennium, in most families, women remain the person responsible for purchasing, preparing and providing food to all members40, the vulnerabilities that affect them affect everyone. Therefore, it is very important to extend a support network to these women. Therefore, considering the newborn’s total dependence on the conditions that influence the mother, it is mandatory to consider the factors that enhance social vulnerability, such as the presence of FI, as a health and nutrition problem for newborns and children.
Breastfeeding was evaluated in this study, and it is important to emphasize that even in the hospital environment, it represents the most adequate food source for newborns. It is responsible for the adequate supply of nutrients and functional and immunological elements such as immunoglobulin A, ensuring a beneficial intestinal microbiome capable of decreasing intestinal colonisation by pathogenic bacteria, as observed by Boccolini et al. (2013)41. According to the authors, breastfeeding in the first hour is essential for the prevention of neonatal complications and even mortality, as observed in studies with demographic and health data from 67 countries. However, inadequate hospital procedures and adverse sociodemographic factors can compromise breastfeeding in the first hour of life42.
Breastfeeding not only prevents risks to child health but also future illnesses, such as obesity, hypertension, diabetes and other chronic diseases in adults7,8.
The current and future panorama of food and nutrition security in the world points to problems of a global syndemic that involves the paradox of maternal obesity together with malnutrition in children under 5 years of age43. In this panorama of malnutrition, early weaning plays a preponderant role, and the unfavourable eating environments that involve the mother-child pair in an FI situation potentiate the syndemic.
Therefore, the efforts of the hospital neonatal health team must include the prevention of adverse factors that protect the practice of breastfeeding in the first hours of life and even before (i.e., in prenatal care), where information for pregnant women must include guidance on breastfeeding even in the birth room. Although this study did not investigate this consumption in the first hour of life, which may represent a limitation, it did so on the first day of life, which is an early identification of breastfeeding in the immediate postpartum period42.
In the present investigation, the proportion of newborns given breast milk at birth was high (approximately 90%), which converges with the practices of the initiative of a programme called “Baby-Friendly Hospital” in Brazil. This is a programme that accredits hospital units that encourage breastfeeding practices in their neonatal units and paediatric wards 44.
In the present study, it was possible to verify that newborns from households with some degree of FI had a greater chance of not consuming breast milk on the first day of life than those in an FS situation (OR = 7,0; 95% CI:). This is an impactful result, considering that it can have very harmful immediate and future consequences for the health of the newborn and may contribute to the worsening of nutritional conditions in respiratory diseases45, digestive disorders and food allergies46.
It is important to consider that breastfeeding meets all the criteria of food and nutrition security for babies. Promoting access to safe nutritional needs and the absence of breastfeeding in an FI situation is a real paradox, and the few financial resources available to families in this situation should be a stimulus for maintaining this ideal practice for newborns and older children 45.
The literature reveals that the association between FI and breastfeeding can be controversial. Hanselmann et al. (2018) evaluated breastfeeding in infants and newborns associated with household FI and found that FI was related to the early introduction of cow's milk in families that had dairy cattle13. Similarly, Gomes and Gubert (2012)47 evaluated FI in children and infants in Brazil and demonstrated that the practice of breastfeeding was more prevalent in children from households with FI (approximately 41% of breastfeeding) than in those with FS (approximately 29% of breastfeeding). Despite this fact, approximately 70% of infants under 6 months of age in FI households were already receiving other foods in addition to breast milk. These two studies, however, did not include situations involving childhood morbidities or the need for hospitalization of newborns that can make breastfeeding difficult48.
Social factors associated with FI that increase the substandard condition of women's lives, such as low education, low income and lack of a partner, can affect breastfeeding in the neonatal unit, since they decrease the permanence of mothers in the neonatal unit to breastfeed their child and increase maternal stress, which further reduces the practice of breastfeeding. Thus, other eating strategies, such as a cup, “finger feeding” or even a gastric tube, will be used for a longer period of time, which prolongs the length of stay of these newborns in the hospital49. Additionally, insecurity in the effectiveness of breastfeeding, such as the frequent belief of producing “weak” milk10, can occur in women experiencing FI and discourage breastfeeding practice.
Emotional support did not seem to be an important factor related to the early consumption of breast milk, since there was an inverse relationship between this dimension of social support and breastfeeding (OR = 1.04; CI: 1.01-1, 1), indicating that women who perceived themselves as having a support network for solving their emotional problems had a higher risk of not providing breast milk to their newborn. Additional investigations are needed to clarify whether there were factors confounding this relationship in addition to those already highlighted in Table 2. However, it is possible that the anxiety of not being able to provide the baby with nutrition via breastfeeding, which pregnant women usually experience, can be alleviated with a social support network that can reassure the mother and make her believe that there are alternatives supposedly as efficient for the nutrition of her child as breastfeeding, thereby discouraging her from this practice. These findings suggest that feeling supported does not effectively reflect the quality of support that is actually received.
Reeves et al. (2006) investigated the intention of mothers to breastfeed for up to 6 months, evaluated the social support they received and found that in 62.6% of cases, women expressed that the social support system in which they were involved did not influence her own decision to breastfeed50. Contrary to this finding, Bertoldo et al. (2019) found that positive/affective interaction support was one of the determinants of breast milk consumption (OR = OR = 1.52 95% CI = 1.03–2.25) in children of employees of a university in Rio de Janeiro (Brazil)14.
In the present study, the presence of diseases prior to pregnancy was also a major factor in breastfeeding at birth, increasing the chance that newborns would receive industrialized formula in their diet instead of breast milk by approximately 7 times. This fact points to the importance of prenatal care with specialised and more frequent attention for pregnant women who have a disease before pregnancy or who bring this complication to the current pregnancy.
Strategies to encourage breastfeeding, such as helping in the search for solutions to the obstacles that diseases in pregnant women can bring to breastfeeding and clarifying which diseases are real and which are the result of wrong information, should be adopted from the beginning of precare birth by obstetricians, nurses and nutritionists. However, the guidelines published by government health agencies are somewhat restricted in this information, limiting themselves to good maternal health conditions. Efforts are needed on the part of health professionals regarding the proper guidance of mothers and providing family support. Public managers must encourage professionals to be more dedicated to this practice.
Among the clinical complications and diseases that affect newborns, those related to the respiratory system, including neonatal asphyxia, are one of the most frequent, especially in preterm infants, with the highest prevalence after infections in term babies51. Although most newborns in this study did not have diseases, and, among those who did, the highest proportion were those with congenital infections, respiratory morbidities were most associated with the use of exclusive artificial feeding, which increased the chance of this type of feeding by approximately 25 times. This finding is well referenced in the literature since, even in good health conditions, breastfeeding is not an easy task, and early weaning is a frequent reality 52.
Even though breast milk is an expressive protective factor against respiratory diseases in childhood9,53, when they affect the newborn, they make the suction-swallowing process difficult, and the mothers are usually not able to perform manual expression of the breasts for milk extraction. In addition, there is the possibility of reducing the flow of milk due to the stress caused by hospitalisation, which reduces the hormone oxytocin52. This fact points to the essentiality of multidisciplinary actions to continuously support breastfeeding techniques.
The results of this study were instructive in relation to the role of FI and social support in early breastfeeding; however, this study has some limitations. In regard to the evaluation of gestational weight gain, it was not possible to verify the quarterly gain in the women's medical records; only the total weight gain was obtained. Regarding the assessment of breastfeeding, this practice was recorded on the first day of life, but it was not possible to record it in the first hour of life, which has been identified as valuable for the extension of breastfeeding duration, among other advantages for child health. It was also observed that the consumption of BM was inversely associated with emotional support, and it is possible that confounding factors that were not evaluated in this study interfered with this relationship. A final limitation mentioned refers to the lack of registration of the types of complications during childbirth; only the presence of these complications was registered. This information would possibly improve the knowledge of its relationship with neonatal diseases and even with the consumption of breast milk. These limitations, however, do not compromise the validity and importance of the findings of this study.