Breastfeeding practices of ethnic Indian immigrant women in Melbourne, Australia

Ethnic immigrant Indians and breastfeeding

Breastfeeding is universal and prolonged in India [15–17] – both in urban and rural areas – and continues into early childhood years [18–20], but initiation is delayed because of the perception that mother’s milk flows two to three days after childbirth [21]. Indian mothers do not exclusively breastfeed in India due to traditional practices; the exclusive breastfeeding rate in India was 46% at less than six months in 2005–2006 [22]. The varied cultural practices associated with lactation and breastfeeding in India include anything from exclusive feeding to varied amounts of prelacteal and supplemental feeding with infant formula and other types of animal milk [8].

Not much is known about this particular group of women’s breastfeeding practices in Australia, although Indian ancestry immigrants constitute two per cent of the Australian population [23] and this percentage is likely to increase in the near future. In the last few decades, there has been a significant increase in the number of ethnic Indians migrating to Australia. Victoria has the largest group of ethnic Indian residents in Australia. Melbourne has a heterogeneous population of Indians with regard to religion, language, and place of origin. They are one of the larger new immigrant populations and comprise peoples from India as well as Fiji, South Africa and the United Kingdom amongst other Indian groups. Despite this, there is limited literature on Indian immigrant experiences in Australia, hence, very little is known about their culture and their needs in Australia. Still less is known about the way they acculturate to their new environment, in particular, the way in which they adapt to parenting. Although research on Indians settling in different Western societies has been documented in acculturation literature, there is no evidence on how acculturation and identity impacts breastfeeding practice amongst Indians in Australia. Therefore we explored one aspect of parenting in depth and examined how cultural identity construction influenced breastfeeding initiation and duration among ethnic Indian immigrants in Melbourne.

Study participants

Ethnic Indian women born in India, Fiji, the United Kingdom and South Africa were recruited for this study. They were all first generation immigrants to Australia. Some were established immigrants having migrated as children with their families and others had migrated as adults for economic reasons between five and 10 years prior to the study. Of the recently arrived women, many had migrated with their husbands or to marry resident Indians in Australia. Women who met the following criteria were recruited in the study: in the third trimester of pregnancy and identified as an ethnic Indian immigrant. During the course of this study participants were expecting a child, gave birth and introduced to solids. All were from middle-class backgrounds; the majority had a tertiary qualification and about half were in paid employment. Secondary participants were members of the women’s family who were present in the home during data collection and who wanted to participate in discussions and gave consent to be tape-recorded. Women have been given pseudonyms when quoted.

Study site

The study was conducted in metropolitan Melbourne, specifically areas in north-western, north-eastern, and south-eastern suburbs of the city as the Indian population is concentrated in these areas. The interviewing and observation of primary and secondary participants was conducted in women’s homes by NM.

Data collection

Opportunistic sampling occurred with the assistance of six Indian obstetricians and gynaecologists practicing in metropolitan Melbourne. As this was part of a larger project, because of convenience and timeliness, only Indian doctors were targeted. Ethnicity was not recorded in public hospitals during the study period, hence sampling and recruitment was limited to Indian doctors for maximum exposure. Twelve case studies were collected using ethnographic methodology including participant observation and in-depth interviews with women and their families, in their homes, over a 12 month period. The broad themes of immigration, acculturation, identity, and the cultural context of mother and infant care and child rearing were explored. Data collection instruments included face-to-face in-depth interviews, case-studies, participant observation and life histories.

For each individual case study, a series of in-depth, semi-structured interviews and unstructured/informal conversations with the woman were conducted over a period of time. Interviews were conducted in English as all women were fluent in English. All interviews were audio-taped with the participant’s consent and later transcribed for accuracy of information. Observations were also noted immediately after visits with the women.

Mothers were followed for approximately 12 months, from before they gave birth to when they began introducing their infant to solid foods, and beyond. Information on women’s intentions to breastfeed was collected before birth and information about their actual practices was collected after birth. Due to the explorative and iterative nature of qualitative research, new themes continued to emerge throughout the interview process, and each successive interview was initiated with these themes in a semi-structured manner to facilitate open-ended discussion. These themes were also validated by the participants at the beginning of each visit. A semi-structured interview guideline was developed and this was adapted after each interview to accommodate emerging themes. Data collection continued until data saturation was reached, that is, until no new themes emerged.

Data analysis

Data analysis was conducted using a general inductive approach [24]. The interview transcripts were analysed through multiple readings developing themes or categories. Broad or general categories were derived from the study aim and specific themes from the data objectives. These resulted in summarising categories that enabled the identification of themes, which were most relevant to the research objectives. Finally, frequent, dominant, or significant themes observed in raw data were identified in all of the case studies; divergent experiences were also accounted for in the analysis, that is, divergent views that emerged during analysis lead to further sampling to check whether the phenomenon was atypical, ensuring that diversity of experience was transparent in the findings. Themes were then crosschecked with participants for accuracy and verification of data gathered in previous interviews in order to maintain trustworthiness of the data, and to prevent researcher bias in the data analysis. Sampling continued until no new themes emerged, that is data collection ceased when the same themes were being reiterated.

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

Limitations of the study

One limitation of the study is the relative economic homogeneity of the study sample as all women were middle class and educated and came to Australia through skilled migration or as a result of marrying someone who came to Australia through skilled migration; although the study sample includes women who were born in India, Fiji, the United Kingdom and South Africa, and women who were newly arrived, established, and had been here since childhood. Not all segments of the Indian community could be included, therefore, findings may not be generalisable to other socio-economic sub-groups of immigrants from South Asia. However, it is the depth of information gathered, and not the breadth or statistical representation that is important in an ethnographic study; hence, this has not compromised the credibility of findings from this research.

Implication for practice

The cultural approach of immigrant women needs to be understood and remain at the foreground of any discussions on mother and infant care and feeding. However, we also need to bear in mind the cultural variability of ethnic Indian women due to the diasporic nature of the Indian population worldwide, the various birth places and differing levels of exposure to Western culture, and to assess a woman’s acculturation before assuming her understanding of Western models of childcare and rearing.

Support is a cultural expectation amongst Indians, where family and community (elder familial females traditionally and husbands and ethnic community in Australia) support and promote breastfeeding through traditional aspects of care during the postpartum period. In the case of recently arrived women lacking family and established community networks, ethnically specific peer support could be introduced at hospital to assist with the cultural aspects of breastfeeding. This could be followed through at women’s homes after discharge. This could help both Indian women and provide a possible model for intervention for other immigrant women in Australia.

In understanding women’s experiences and decisions regarding breastfeeding, the social and cultural context should be taken into account. In the case of Indian immigrants, the extended family, such as mothers and mothers-in-law who have an integral role traditionally, husbands who have an active role in Australia and health professionals who are looked upon as experts are all critically important to breastfeeding. It is therefore essential that health professionals who come into contact with new mothers are knowledgeable about the benefits of exclusive breastfeeding and about how to best encourage and support breastfeeding mothers to continue exclusive breastfeeding.