Women in this study were from urban areas in India, Fiji, the United Kingdom and South Africa. Most had tertiary education and half were involved in paid employment. They were between the ages of 26 and 42 at recruitment and first interview, with most being in their late 20s. All were married and expecting a child when first interviewed, with seven of the 12 women having had other children. Five women were recently arrived immigrants; another five had immigrated between five and 15 years prior to interview and two had immigrated as children. Most women immigrated after getting married to men who were already resident in Australia.
All women identified as ethnic Indian, had pride in their cultural heritage, and had intentions of initiating breastfeeding in accordance with this ethnic and cultural identity. Motherhood is highly valued in Indian culture and women are defined, communally and personally, by their role as mothers. Breastfeeding is an integral aspect of mothering and is, consequently, seen as natural and normal. Therefore, unsurprisingly, all women in this study initiated breastfeeding. However, their acculturation and sense of identity - cultural and gendered - played an important role in the maintenance and duration of breastfeeding. This was seen through factors such as employment status, cultural connections and social support as well as advice from health professionals that influenced women’s breastfeeding practice.
Knowledge of breastfeeding
Overall, women were knowledgeable about breastfeeding. This knowledge came from either their cultural and traditional practices – as taught by their mother or mother-in-law or by observing what female relatives did in their home country – or from professional recommendations in Australia. Women were aware that traditionally the recommendation was to breastfeed for as long as possible as it is ‘healthy’ for the baby. Additionally, they were aware of the practice of demand feeding and anticipated following this practice in Australia. They were also aware that Australian health professionals recommended exclusive breastfeeding for six months, and thereafter to maintain breastfeeding for at least a year.
Prenatal intentions to breastfeed vs actual initiation and duration of breastfeeding
Women’s intentions to breastfeed were inexorably tied to their cultural identity and heritage. During antenatal interviews their intention to breastfeed was clear and steadfast. All women had intention to breastfeed, as ‘this is what Indian women do as mothers’, and were intent on breastfeeding for a minimum of six to 12 months.
However, after childbirth women’s practice differed from their initial intention. All women initiated breastfeeding immediately after birth as instructed by their midwives. However, when women felt that they experienced breastfeeding difficulties, infant formula was introduced. All but one woman gave infant formula during the course of breastfeeding and most began infant formula feeding before six months of age, with five starting at hospital. Duration of breastfeeding declined with several women breastfeeding for a far shorter duration than originally intended and few breastfeeding for 12 months. Usually breastfeeding was abandoned earlier than intended because of the confusing messages given by health professionals. Some women said they were asked to follow a feeding schedule and not to demand feed, which undermined their traditional approach to breastfeeding thus affecting their confidence in their ability to care for their baby.
Health professionals seemed to have a significant influence on women’s decisions regarding supplemental feeding, which influenced their breastfeeding practice. This was more apparent amongst the recently arrived women who looked to health professionals for guidance in appropriate healthcare and for what is ‘right’ in Australia.
My mother told me that it is very good to breastfeed, but according to the advice of the doctors here, I started him [baby] on formula. My mother insisted that it is good to have breast milk. Yes, I think sometimes he [baby] is not satisfied with my milk because he needs something more. I am not saying that my breast milk is not coming, maybe his capacity is more. The maternal and child health nurse/midwife told me to give him one or two bottles a day, but also to continue with my breast milk. (Preeti)
Preeti knew that breastfeeding is the traditional way of feeding and is best for the baby but like other recently arrived women, she was influenced by her health professional to start supplementary feeding. Women like Preeti were easily swayed by health professionals whom they felt ‘know best’ and could advise upon the ‘right’ way of doing things in Australia.
Major factors impacting on breastfeeding
Paid employment
Women in paid employment felt that they had to cease breastfeeding before resuming work. Therefore, women on maternity leave started weaning their infants prematurely even though they had intended to breastfeed for longer prenatally. These women wanted their babies to get accustomed to bottle feeding. Expressing breast milk was seen as time consuming and inconvenient (also this is not practiced in their home country and is unfamiliar) so breast milk was substituted with infant formula (which is easily available) when women were at work, and breastfeeding eventually ceased:
Breastfeeding, in India it is a must. If you don’t you are sort of looked down upon like you are not doing the right thing as a mother. Because I fed Leila [when at home] till she was about 10 months, and we went to India when she was about 14 months, and back there people are still breastfeeding their babies till they are past a year old, so you had to answer to them. ‘Why aren’t you feeding her? You should still be feeding her!’, and I said, ‘No, I can’t feed her because I am back to work now’. (Nina)
Nina had migrated from India over ten years prior to the study and felt that she was acculturating to an Australian way of life. For Nina, gaining a sense of belonging here meant adopting Australian gender norms. As well as needing to work to maintain a good standard of living, she wanted to work as she felt this made her independent and gave her an identity apart from ‘mother’. She saw herself as a Westernised Indian and felt that this set her apart from recently arrived Indian women, such as her sister-in-law, whose adoption of the traditional gender role for Indian mothers did not accommodate working outside the home.
Nina was on maternity leave when she had her baby and knew that she had to return to work in a few months, so she began weaning in preparation. She was educated and understood the benefits of breast milk but also felt that expressing took up a lot of time and effort when she had to balance duties at home and work.
Employed women stated that they were aware of the benefits of exclusive breastfeeding for six months and continuing breastfeeding beyond. Also, they knew that this is what Indian mothers do, and that it is highly recommended by Australian health professionals. However, they felt that to prosper in Australia both husband and wife had to work. Also, the values of this society meant that women needed to embrace roles other than ‘mother’ to feel accomplished. Acculturating women were dealing with a shift in personal identity from the traditional Indian mother to incorporating a more Westernised gender roles. This impacted on their breastfeeding behaviour and practice.
Advice of healthcare professionals
Recently arrived women relied on the advice of health professionals for the ‘right’ approach to breastfeeding in a culture that was new to them. Most women had positive overall experiences with health professionals. However, some women reported confusion and stress surrounding breastfeeding when they were shown more than one position to breastfeed in, when they were told about feeding schedules as well as demand feeding and when they were offered infant formula when unsure about the adequacy of their milk supply:
They [midwives] said ‘three hours, after that, five hours’, that’s it. They [midwives] didn’t mention anything like, ‘sometimes the baby feels like breastfeeding’, they didn’t tell me anything about that, but my Mum told me ‘If she feels like taking breast milk, just give her, don’t hesitate to give her whenever she feels like it’. . . In the hospital they [midwives] used to give formula, because maybe I didn’t have enough milk. (Rohini)
Rohini had recently arrived in Australia and had been living in Melbourne for just two years. She was unemployed and her husband worked long hours. She had no family or other social networks. She said that she felt lonely and missed her family, more so after childbirth with no friends or community support. This impacted on breastfeeding especially when she felt that she did not have enough milk. She knew that according to her culture she should breastfeed her child as she had seen other women in her family do, but felt that this was difficult without support and encouragement. She spoke to her mother in India on the phone for reassurance but could not help being influenced by Australian health professionals whom she thought ‘know best’.
Support is integral in the Indian conceptualisation of motherhood. Senior extended family members such as mothers, mothers-in-law and sisters-in-law are often present during the postpartum to assist new mothers. Their advice and opinions are highly valued and relied upon, and their role is central to infant care. They are also role models and not having them in close proximity after childbirth robs women of guidance and support.
Cultural isolation and lack of social support
Recently arrived immigrant women who were not employed and who did not have any extended family here felt ‘lonely’ and ‘out of place’ after childbirth. In India, hospitals allow the practice of ‘rooming-in’ where a female family member is allowed to stay overnight with the new mother to assist her with caring for the baby and initiating breastfeeding. There is also a confinement period during which mothers and mothers-in-law take care of the new mother and baby and support breastfeeding, once they return home. Since these cultural systems are not in place in Australia, women felt they could not have the level of rest and assistance at hospital or at home that they would have liked to facilitate successful initiation and maintenance of breastfeeding. Most extended family did not live in Australia and visited for short periods of time, leaving many women depending on their husband’s support:
When Rishaan was in hospital, I think it was the second or third night, he got really hungry obviously. And this night I started crying because Kiran [husband] was not there at that time, and I didn’t know what to do and there was no milk coming out. And because I was stressed out the nurses just said to me, ‘look, it is up to you if you want to give him formula’, and I just said ‘yup, that is it, do it’. (Ria)
Ria who migrated from Fiji over five years prior to the study and did not have her own family around after the birth of her baby to engage her in the customs and traditions that support breastfeeding, relied on her husband for encouragement. However, he was at work during the day and the absence of elder women meant that Ria felt overwhelmed and unsure of herself at this vulnerable time. Difficulties with breastfeeding - her child did not attach to the breast and she felt that she had insufficient milk - compounded this lack of familial support and lack of confidence, impacting negatively on breastfeeding.
For women with no extended family support, husbands and health professionals become important in the decisions surrounding infant care. Health professionals, due to their education and expertise in this area, as well as their positions of authority, are looked upon, often unquestioningly, for advice and guidance.
In contrast, breastfeeding practice was positively impacted when women felt culturally connected and socially supported:
I will do it [breastfeed] anywhere, I have never had any issues…all the time, wherever they needed it, I just did it…she [her mother] was exactly the same, Mum never worried about breastfeeding anywhere (Patricia).
Patricia migrated to Australia as a child with her family and married an immigrant man who had also migrated to Melbourne as a child. She knew that she wanted to breastfeed her babies but unlike the newly arrived women in this study, she was well established in Australia, had community networks and support systems in place and had more confidence in her ability to navigate motherhood. She said that breastfeeding was something that her mother did and that she was going to do the same. Patricia’s mother, after whom she was modelling her mothering approach, was also in Melbourne and Patricia felt confident in her dual Indian-Australian identity. The interviewer observed Patricia breastfeed on demand on many occasions, in keeping with the traditional way of feeding, without regard for scheduling feeds. Patricia exclusively breastfed all her children and ceased breastfeeding each child only when she became pregnant again. Her confidence in what she knew to be best for her babies seemed to be fuelled by having her role model (mother) present and by her sense of belonging in Australia. She did not feel that she had to defer to what others were advising as she was informed and secure in her own beliefs.
Unlike acculturating women, who were still trying to cement their belonging in Melbourne and wanted to fit into the prevailing cultural system, Patricia grew up in Australia and felt that she had nothing to prove by conforming to Australian gender roles. She also strongly identified as Indian, communally as well as personally, and prioritised her role as ‘mother’, wanting to mimic the Indian way of mothering that was passed down to her by her mother, which included totally devoting herself to the care and raising of her children for the time being. Patricia had strong opinions on what she saw as being the positives of Indian motherhood and was proud of asserting these practices and values. She was also able to stay at home to care for her children without the pressure of having to return to paid employment, was involved in her cultural community and had the daily support of her family (husband, mother and father) for whom breastfeeding was a normal and valued practice.
For the majority of women in this study, when mothers and mothers-in-law were not around in the postpartum period, women depended on their husbands to reassure them in their efforts to breastfeed. Those who had their husband’s encouragement, and were well supported by extended family and other social networks and felt culturally connected were able to persist in their attempts at breastfeeding despite difficulties such as problems with attachment and soreness of nipples. By contrast, those who were introduced to infant formula at hospital, whose husbands viewed infant formula feeding as a good option and had no family or community networks, felt comfortable supplementing with infant formula when breastfeeding seemed difficult or inconvenient. Since their midwives had offered this option it seemed like an acceptable and comparable method of feeding to women who were culturally and socially isolated and heavily dependent on the advice of health professionals.