Breastfeeding practices among South Asian immigrant women in Canada

Breastfeeding Among South Asian Immigrant Women

"Their Future is Now: Healthy Choices for Canada's Children & Youth" states: "More women are now starting to breastfeed their babies (85 per cent in 2003 compared to 75 per cent in 1995) which contributes to healthier babies and strengthens the important bond between mother and child. However, in 2003, only 19 per cent of recent mothers reported breastfeeding exclusively for at least six months, as recommended by the World Health Organization and the Canadian Pediatric Society. This highlights the need for more support for women to breastfeed, and more information on the factors that prevent women from breastfeeding." (2006) the work of the World Health Organization entitled: "Exclusive Breastfeeding" states that breastfeeding is an "unequalled way of providing ideal food for the healthy growth and development of infants; it is also an integral part of the reproductive process with important implications for the health of mothers." (WHO, 2005) Evidence supports exclusive breastfeeding for a period of six months as the "optimal way of feeding infants." (WHO, 2005) it is recommended by the WHO and UNICEF that breastfeeding should follow the guidelines as follows: (1) Initiation of breastfeeding within the first hour of life; (2) Exclusive breastfeeding - that is the infant receives only breast milk without any additional food or drink, not even water; (3) Breastfeeding on demand - as often as the child wants, day and night; and (4) No use of bottles, teats or pacifiers. (WHO, 2008) Breast milk is not only "the natural first food for babies" providing all necessary energy and nutrients needed by the infant in the first six months of its life but as well "continues to provide up to half or more of a child's nutritional needs during the second half of the first year, and up to one-third during the second year of life." (WHO,

Breastfeeding is natural but it is also a "learned behavior" and a great deal of research has shown that "mothers other caregivers require active support for establishing and sustaining appropriate breastfeeding practices." (WHO, 2005) Towards this end, WHO and UNICEF report having launched the Baby-Friendly Hospital Initiative which is focused toward strengthening the maternity practices to support breastfeeding. This initiative has been implemented in approximately 16,000 hospitals worldwide.

The work entitled: "The Impact of a New Universal Postpartum Program on Breastfeeding Outcomes" states that rates of breastfeeding initiation in Canada increased "...significantly between 1996/1997 and 2003 from 73% to 84.5% respectively." (Sheehan, Watt, Krueger, and Sword, 2006; 398) Canada has set out new guidelines in a draft on infant feeding and states recommendations of "exclusive breastfeeding until 2 years of age and beyond..." (Sheehan, Watt, Krueger, and Sword, 2006; 398) Initiation rates are stated to have improved however, there are still only approximately 48% of mothers in Canada who are still breastfeeding at four months following delivery and only approximately 38% are breastfeeding "exclusively" meaning that the infant is being fed only breast milk with no additional liquid, food, or even water. It is noted in the work of Dennis (2002) that the primary reason women quit breastfeeding is "because of perceived difficulties with lactation rather than material choice." (Sheehan, Watt, Krueger, and Sword, 2006) Sheehan, Watt, Krueger, and Sword state that Ontario introduced a universal program in 1999 for all women following delivery which is known as the 'Healthy Babies, Healthy Children Program (HBHC) which is a hospital stay and postpartum home visiting program containing three components:

1) all women have the option of staying in the hospital for up to 60 hours after a vaginal birth, (2) a public health nurse conducts a telephone assessment with all consenting postpartum women within 48 hours of hospital discharge, and 3) all postpartum mothers are to be offered an in-home follow-up visit. (Sheehan, Watt, Krueger, and Sword, 2006)

Conclusions in this study state the following: "Breastfeeding conveys multiple health benefits for mothers and newborn infants and is encouraged by most health professionals. However, in Ontario it appears that some women leave the hospital without the personal or structural resources to continue successful breastfeeding. The findings of our study suggest that the provision of a single postdischarge phone call, and the offer and/or acceptance of a postpartum home visit through HBHC, is insufficient support to maintain breastfeeding to 4 weeks postpartum. If one wishes to increase breastfeeding continuation rates, it is possible to address those factors associated with discontinuation by 4 weeks postdischarge." (Sheehan, Watt, Krueger, and Sword, 2006) Stated additionally is that public education on a continuing basis in focused on supporting the provision of knowledge to new mother concerning the integral value of breastfeeding towards the end that women are encouraged to breastfeed and desire to gain the necessary knowledge to make this a successful endeavor and in assigning the proper valuation to these benefits. Secondly, it is critically necessary that it is ascertained specifically what policies and practices in the hospital setting are most supportive of mothers in the breastfeeding of infants toward providing the natural immunization needed for the infant's health progression and healthy developmental future. " (Sheehan, Watt, Krueger, and Sword, 2006)

The work of Ruth DeSouza entitled: "new spaces and possibilities: the adjustment to parenthood for new migrant mothers" states: "parenthood and migration are both major life events which, while stressful, can be mediated effectively in a new country without support, networks or access to information creates additional stressors." (2006) reported as 'key' findings in the study were the following:

1) Migrant women lose access to information resources, such as family and friends, in the process of Migrating and come to depend on their husbands, health professionals and other authoritative Sources. Importantly, the expectations from their country of origin come to inform their experiences of pregnancy, labor and delivery in a new country;

2) migration has an impact on women's and their partners' roles in relation to childbirth and Parenting. The loss of supportive networks incurred in migration results in husbands and partners Taking more active roles in the perinatal period; and 3) coming to a new country can result in the loss of knowledge resources, peer and family support and protective rituals. These losses can lead to isolation for many women. (DeSouza, 2006)

DeSourza states that findings in this study include those as follows:

1) support services for women who have a baby in a new country need to be developed and services also need to be 'father-friendly';

2) the information needs of migrant women from all backgrounds need to be considered in planning service delivery (including European migrant women);

3) services need to develop linguistic competence to better support migrant mothers, for example by providing written information in their own language those developing antenatal resources must consider the needs of migrant mothers; for example, by having antenatal classes available in a number of common languages, eg Korean;

4) workforce development occurs among health professionals to expand existing cultural safety training to incorporate cultural competence; and 5) health and social services staff must become better informed as to the resources that are available if they are to provide effective support for migrant mothers. (DeSouza, 2006)

The work entitled: "A Multicultural Perspective of Breastfeeding in Canada" states: "Culture can be defined as the values, beliefs, norms, and practices of a particular group which are learned, shared and which guide attitudes, decisions and actions in a patterned way. Breastfeeding in Canada reflects diverse cultural norms and practices." (Canadian Minister of Health, 1997) This work reports a study conducted on Canadian communities concerning patterns of breastfeeding and practices of feeding infants in Canadian culture. In the initiative of research in this area this work relates several key considerations stated as follows:

1) There tends to be as much, or more, variation among individual members of the same cultural group or community as there is among different groups or communities. Variations can occur in language, behavior, concepts, interests, beliefs and values, as all are influenced and mediated by individual experience;

2) Generalizations are inherent in cultural profiles and are necessary for discussion or illustration purposes. However, 'they should not be interpreted as representing characteristics applicable to all or, in some instances, even most of the individuals within a community. Generalizations may, in fact, be completely inappropriate when applied to any specific individuals or circumstances without regard to the individual or circumstance; and 3) Individuals from the same socioeconomic levels but different cultural groups are likely to have more in common, including health beliefs and behaviors, than those from different socioeconomic levels within the same cultural group. Some socioeconomic characteristics such as education, occupational status and access to health opportunities may transcend cultural barriers." (Canadian Minister of Health, 1997)

Duration of breastfeeding is related to factors which affect that during including formula being fed to the infant in the hospital and readmission to the hospital as well as infant visits to a walk-in clinic. While mothers in this study were not asked specifically whether breastfeeding was discontinued as a result of these events. Data in this study indicates that these events preceded the discontinuation of breastfeeding. The following figure illustrates the Schema for Breastfeeding Definition provided by the Canadian Minister of Health (1997) which was adopted from the work of Labbok and Krasovec (1990)

Schema for Breastfeeding Definition

Source: Canadian Minister of Health (1997) adopted from the work of Labbok and Krasovec (1990)

Vietnam and Cambodian Cultures Examined

Several cultures are examined in this study including those of the Vietnamese, Cambodians and those from Laos and it is stated the largest part of these children "are typically breastfed for more than year." (Canadian Minister of Health, 1997) it is related that imported formula is not affordable or not readily available therefore, breastfeeding is "simply the norm." (Canadian Minister of Health, 1997) This work relates that when no supplement formula is available that breast milk "is commonly supplemented with prechewed rice paste or rice and sugar porridge." (Canadian Minister of Health, 1997) at six months of age the child's diet begins to include "a thin gruel of boiled rice flour (bot) followed by porridges." (Canadian Minister of Health, 1997) it is related that infants in urban areas of Vietnam nd Cambodia "are more likely to be formula-fed." (Canadian Minister of Health, 1997)

The work of Serdula, Cairns, Williamson and Brown (1991) states that 93% of children from Southeast Asia were breastfed "in their country of origin" while of those born in the U.S. only 10% were breastfed with a similar trend reported among Hmong refugees. Among Hmong women living in Thailand refugee camps it is reported that 88% had plans to breastfeed their infants until the next child was born however, "following immigration breastfeeding initiation rates appeared to fall off sharply." (Serdula, Cairns, Williamson and Brown, 1991) it is related that this patterns "appears to reflect the Canadian experiences as well." (Serdula, Cairns, Williamson and Brown, 1991) it is related that the reason primarily stated for switching the infant from breast milk to formula is generally "the perception of insufficient milk supply." (Serdula, Cairns, Williamson and Brown, 1991) it is embarrassing for Vietnamese women to breastfeed in public and furthermore, it is stated by Leininger (1987) to be "potentially dangerous, particularly in the workplace" and additionally breastfeeding is generally stopped when the mother returns to school or work. Many times, the mother will employ a wet-nurse to continue breastfeeding the infant if they are able to afford it. The view of Indochinese women is quite different from that of women in the United States in that Indochinese women "feel that breastfeeding may make them too skinny and drain their energy" while women in the United States are glad that weight loss accompanies breastfeeding." (Serdula, Cairns, Williamson and Brown, 1991)

Sri Lankan Tamil Culture

It is reported that in Sri Lanka, the norm is breastfeeding of infants however, most recently formula and cow's milk has been used by women who must return to work quickly and those who are not able to breastfeed. For women who do not work outside the home breastfeeding takes place for longer period than for those employed. Tamil women in Canada do still breastfeed and switch to formula at the time the infant is four months old or sooner if they must return to work. The Tamil culture requires the mother and the new baby to remain confined to home for the first thirty days following childbirth. The mother limits water intake and is allowed to consume no fruits, vegetables or juices however after the first five days, the mother is allowed fresh fish and chicken followed by certain vegetables. The chosen foods are believed by the Tamil culture to increase and improve breast milk as well as the strength of the mother.

Japanese Culture

Japanese culture highly values children and is viewed as the woman having becoming complete. The role of women in the Japanese culture is one in which traditionally involves rearing children and as well nurturing them. It is stated that "within this context, breastfeeding is viewed as very positive and very necessary for the health of children. As such, it is promoted in all segments of society." (Canadian Minister of Health, 1997) the norm in Japan was traditionally prolonged breastfeeding and still today children are often breastfed for long period. The kindergarten application in Japan actually asks the question of "how long was the child breastfed and if the child has been weaned. The work of Riordan notes that more than fifty percent of Japanese mothers are breastfeeding at three months postpartum and that this rate is known to drop to only one-third at six months postpartum." (Canadian Minister of Health, 1997) the work of Chan-Yip and Kramer (1983) states findings that the Chinese women participating in their studies were not aware of support services regarding breastfeeding and as well were unaware of where they could receive "assistance with lactation." (Canadian Minister of Health, 1997) the Canadian Minister of Health states: "Further research is needed regarding infant feeding patterns, both pre- and post-immigration, and on cultural beliefs and practices related to infant feeding in Canada. Research is needed to determine the best ways to support lactation and promote breastfeeding among all cultures." (1997)

The work of Health Canada entitled: "Immigration and Health" states that "Infant care behaviors, such as breastfeeding have a demonstrated relationships to health status." (Health Canada, 2006) it is related that in 1997, Edwards and Boivin made a comparison of the differences "in infant care behaviors between recent immigrants (less than 3 years in Canada) and less recent immigrants (more than 3 years in Canada) using data from participants recruited from five regional hospitals in the Ottawa-Carleton region. Although there were no significant differences in infant care behaviors between the two groups there were differences in maternal variables associated with these behaviors." (Health Canada, 2006) the hypothesis in this reported research is that "the lack of prior experience among primiparas may contribute to diminished self-efficacy, lack of knowledge about health-promoting infant care practices and lack of family support for behaviors such as prolonged breastfeeding." (Health Canada, 2006)

The study states findings that: "data from the NPHS and NLSCY suggested that mothers who identified themselves as immigrants and mothers who spoke a language other than English and/or French were more likely to breastfeed compared to their non-immigrant, English/French-speaking counterparts. Another Ottawa-based study confirmed that women who spoke other languages were more likely to breastfeed than English-speaking mothers. However, since breastfeeding rates in Canada could not be compared with breastfeeding rates in the countries of origin, no conclusions could be drawn regarding whether or not breastfeeding rates had increased or decreased after migration." (Health Canada, 2006) Several studies are stated to have reported that "breastfeeding among immigrants women declined during immigration compared to breastfeeding rates in their countries of origin." (Health Canada, 2006)

The research reviewed in this study indicates that "changes in perinatal health outcomes following migration are attributable to changes in risk factors associated with these outcomes, notably health behaviors, social support and stress." (Health Canada, 2006) it is additionally stated that: "...living in communities with few other Vietnamese families or experienced women to turn to for support explained why Vietnamese women in the United Kingdom reported that they lacked confidence to initiate and maintain breastfeeding. Inadequate resources were allocated when health care workers assumed that women from traditional societies would persist with breastfeeding following migration." (Health Canada, 2006) Studies in Canada are stated to have documented risk for immigrant women who are pregnant which included "isolation due to loss of family support, low income, communication problems and mental health problems." (Health Canada, 2006) Other documentation concerned "linguistic, cultural and informational barriers to prenatal health care..." And evidence which suggested that "immigrant women may not be benefiting from short-stay hospital post-partum programs." (Health Canada, 2006) Suggestions have arisen from which research that suggest that "the need to choose between old and new ways may give rise to four different modes of adaptation." (Health Canada, 2006) Those four modes include:

Assimilation: the relinquishment of cultural identity and movement into the larger society;

Integration: simultaneous adherence to traditional culture and adoption of some dominant societal values;

Separation: the self-imposed withdrawal from the dominant society while maintaining a traditional cultural identity; and Marginalization: alienation from the dominant society together with loss of cultural identity. (Health Canada, 2006)

It is related that three primary themes emerged in the review of literature relating to acculturation:

Levels and rates of acculturation affect many different domains of daily activity (social roles, social relationships, language use and food preference);

The research increasingly portrays acculturation as a bidirectional and orthogonal process, as a result of which individuals acquire, retain or relinquish behaviors and values of both their traditional culture and the new one to which they are adjusting; and Different dimensions of acculturation were associated with different types of outcomes. (Health Canada, 2006)

Dianne Kinnon, in the work entitled: "Canadian Research on Immigration and Health" writes that the role of social support "as a contributor to health has been well established. This finding appears to be borne out among immigrants as well. Separation from family is a particularly important stressor on the initial immigrant..." (1999) Social support is stated to "have a particular meaning for immigrants because their previous social, and in many cases, family support networks have been disrupted: in the case of refugees this disruption is involuntary and likely permanent." (Kinnon, 1999) Additionally stated is: "A study based on the 1990 Ontario Health Survey data also shows that immigrants -- " especially Asians -- " are less likely to be overweight than Canadian-born individuals." (Kinnon, 1999)

Additionally affecting the health of immigrants is the social and physical environment which include: "...the natural environment, environmental hazards, the nature of cities and communities, and the social environment, and could conceivably include the societal and political structure, and the nature of public participation..." (Kinnon, 1999) Kinnon (1999) additionally states: "Housing adequacy and availability constitute an important aspect of the successful integration process and are known to contribute substantially to overall health." (Kinnon, 1999) Kinnon additionally relates that studies which examined the differences of being a refugee among men and women find that "important factors include very different gender identities inherited from the home culture, compared to Canadian norms, as well as differences in perceptions of new opportunities in their new country." (Kinnon, 1999)

Kinnon states that in one study that examined barriers to health care access for Vietnamese refugees identified "problematic interpretation of patient symptoms by health care providers as a major barrier, in addition to lack of health care worker understanding of traditional remedies." (Kinnon, 1999) Furthermore, Carl (1996) in the work entitled: "Perspectives on Racism and the Human Service Sector: A Case for Change" investigated how delivery of services is affected by race and racism in relation to "immigration, settlement and health..." (Kinnon, 1999) Another problem identified in the work of Boyd (1992) in a study of literacy states findings that of adults born outside of Canada 28% have difficulty reading either English or French and that literacy is more problematic for women (32%) when compared to problems of illiteracy for men (24%).

The work entitled: "Breastfeeding Culture and Attachment" states that throughout the world infant feeding practices are adapted "to their own circumstances and the environment they live in." (Factsheet, nd) Cultural traditions include:

1) initiation of breastfeeding;

2) Frequency of breastfeeding;

3) Duration and termination of breastfeeding;

4) Acceptability of breastfeeding in public; and (4) family and community support for breastfeeding. (Factsheet, nd)

Other cultural influences which affect breastfeeding include:

1) How often a child will be held or carried and how the child will be carried;

2) How a child and mother will be clothed; and 3) How a family will sleep. (Factsheet, nd)

It is reported that South Asian women "typically do not participate in breast health practices due to a variety of cultural beliefs and practices. The most commonly held beliefs that may prevent women from breast self-examination includes beliefs on privacy, modesty and general breast health." (Immigrant & Refugee Women's Cultural Health Practices, 2005) South Asian women are instructed at a young age to refrain from exposing their body to strangers resulting in their refraining from "breast self-examination practices that go against the values and beliefs they were taught around modesty. In terms of general breast health women believe that if they keep healthy by eating well, exercising and maintaining a balanced life there is no need for breast screening measures." (Immigrant & Refugee Women's Cultural Health Practices, 2005)