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Analysis

Pakistani women: feeding decisions

4 June, 2008

Pakistani women: feeding decisions

Lecturers Fiona Meddings and Jan Porter of the division of midwifery and women’s health at the School of Health Studies at the University of Bradford detail the difficulties faced by UK Pakistani women in making informed choices on breastfeeding.

 

Lecturers Fiona Meddings and Jan Porter of the division of midwifery and women’s health at the School of Health Studies at the University of Bradford detail the difficulties faced by UK Pakistani women in making informed choices on breastfeeding.

 

 Midwives magazine: July/August 2007

 

Breastfeeding is high on the public health agenda at the moment. There is an abundance of evidence that demonstrates the health benefits. These include lower rates of respiratory and gastrointestinal infection, higher IQ levels and lower obesity among breastfed children (RCM, 2002; Hall and Elliman, 2003; Riordan and Auerbach, 2004). Despite the overwhelming evidence of the benefits, breastfeeding rates have shown little significant increase over the last ten years (Hamlyn et al, 2002). The World Health Organization (WHO) is seeking to increase breastfeeding rates by 2% per annum over the next three years (Department of Health, 2003a). Initiation rates in the UK are around 68%, however they are lower in the north of England at 61%. This is an overall average and it is known that there are lower initiation rates (57%) in women from poorer socio-economic groups (Hamlyn et al, 2002).

 

Breastfeeding audit

 National targets for improving breastfeeding rates were the impetus for undertaking a local audit. Current figures are available on the macro level, that is, for the country and by region and do little to inform local areas of where improvements need to be made. In order to be able to effectively measure any increase in breastfeeding rates and thus the success of any interventions, an audit was undertaken to produce baseline data. An audit directly enhances patient care through a process of systematic review, monitoring of interventions and measurement of improvements (Jones and Cawthorne, 2003).

 

An audit undertaken in a northern England Sure Start area (Hartley, 2003) confirmed the lower breastfeeding initiation rates. The gaining of ethical approval facilitated a retrospective review of maternity case notes to ascertain the following:

  • If skin-to-skin contact had been undertaken

  • Whether the mother initiated breastfeeding

  • Whether breastfeeding was still undertaken upon discharge from hospital and from the care of the community midwife.

 

 Sure Start programmes are aimed at improving the lives of children aged zero to four years old and their families. It is a government-driven initiative targeted at areas of social deprivation where it is known that the health of the community is influenced by a multiplicity of factors (Department for Education and Skills, 2002). The audit was undertaken from notes where the postcodes reflected areas of a majority population deriving from Pakistan. The findings highlighted that breastfeeding initiation rates were very low (43%). By the time the women were discharged from hospital, rates had fallen to 35% and this reduced further to 33% when women were discharged from the care of the community midwife. Skin-to-skin contact and early attachment has been shown to enhance the success of breastfeeding (Hamlyn et al, 2002; Price and Johnson, 2005), yet the audit identified that only 40% of the women had the opportunity to experience skin-to-skin contact with their newborn infant. It could therefore be hypothesised that if more women were given opportunity for this contact, breastfeeding initiation rates could be increased.

 

As the initiation rates of breastfeeding are so low within this predominantly Pakistani community, it is pertinent to explore the reasons behind these figures. A review of the literature has been undertaken to investigate what is known about intentions and decisions regarding infant-feeding, with a view to increasing breastfeeding rates.

 

Search methods

Searches were undertaken by identifying key words and subject terms such as: ‘breastfeeding initiation and duration’, ‘Pakistani women’, ‘feeding intentions’, ‘peer support’ and ‘infant-feeding’ using well-known databases such as CINAHL, MEDLINE and PubMed via the MetaLib web portal. Only primary sources published in peer-reviewed journals were deemed appropriate (Benton and Cormack, 1996). An initial search of the UK literature produced minimal information pertaining to Pakistani women, thus the search criteria was expanded to include international sources. An increased number of articles were retrieved, but still containing little information on Pakistani women. Summers et al (1997) postulates that in the case of Pakistani women, language barriers and a lack of the use of interpreters can lead to problems of access to these women to ascertain their views. Therefore some literature, not specifically related to Pakistani women, has been used where it can be generalised to this and other populations. 

 

Once the literature was accessed, abstract reviews were undertaken to assess their suitability prior to the retrieval and analysis of the full article. Any empirical research included has been reviewed for ethical sensitivity and appropriateness. Articles were scrutinised to ensure that they included details of the four ethical principles of autonomy, beneficence, non-malificence and justice – this included ensuring that participants had provided informed consent (Beauchamp and Childress, 2001).

 

Literature review

The health benefits of breastfeeding are well-documented and although many women are aware of these benefits, they still choose not to nourish their infants this way. This is particularly true of those from disadvantaged areas. A recent study by Mitra et al (2004) indicated that interventions should focus on improving women’s knowledge, enhancing confidence in individuals’ ability to breastfeed and overcome potential barriers to breastfeeding, particularly the lack of social support. Mitra et al’s (2004) study included 694 lowincome pregnant women in the US where improving breastfeeding rates are part of the ‘healthy people’ goals similar to those in the UK. Although Mitra et al (2004) felt that women’s knowledge should be enhanced, Dykes and Williams’ (1999) phenomenological study reported that overemphasis on the health benefits of breastmilk contributed to women’s anxiety about breastfeeding and its continuation. These included anxiety about the perceived quality and quantity of their milk in comparison to formula milk. While Dykes and Williams’ (1999) study involved in-depth interviews with only ten caucasian women, the results are supported by Durdle et al’s (1996) conference presentation. They commented that if breastmilk is viewed as a product and the baby as the consumer, this can cause anxiety in women who compare breast- and formula milk.

 

In a study by Littler (1997), Bangladeshi women were found to delay breastfeeding due to the failure to give the newborn infant colostrum. Data were retrieved from 60 women and 23 health professionals via interviews and questionnaires. A different focus was used for the women and for health professionals, but the main topics were related to early feeding and the giving of colostrum. Midwives held an unfounded view that Bangladeshi women believe colostrum to be ‘poisonous and evil’. The reasons given by the majority of women questioned for withholding colostrum was that it was thin and watery and thus not felt to provide enough nutrients for the baby – they were reluctant to initiate breastfeeding until the ‘rich’ milk was available. Similarly, in a study undertaken by Ingram et al (2003), Pakistani grandmothers were found to encourage their daughters-in-law to discard colostrum as they believe it is stored in the breast for a long time and is therefore old and unsuitable for a newborn baby. This may explain why breastfeeding initiation rates were found to be low in the audit undertaken by Hartley (2003) as the majority of women would have left hospital prior to the perceived ‘rich milk’ becoming available. However, Ingram et al (2003) described an intervention where a home visit was made with expectant mother and mother-in-law pairings to discuss breastfeeding. This resulted in improved initiation rates and the giving of colostrum.

 

Traditionally, Muslim women have perceived the ability to breastfeed as a gift from Allah (Ingram et al, 2003). Grandmothers in Ingram et al’s study (2003) strongly encouraged breastfeeding. They believe the text of the Koran (cited in Littler, 1997) that states that breastmilk should be given to the infant for the first two years. It is acknowledged that not all Pakistani women follow the traditional customs and beliefs, which reflects the diversity to be found in such communities.

 

Carfoot et al (2003) were unable to establish conclusive evidence to support the current initiative of encouraging skin-to-skin contact as a means of increasing the duration of breastfeeding. Despite inconclusive evidence, the practice is one of the steps in the WHO/UNICEF (1998) Baby Friendly Hospital Breastfeeding Initiative, and as such it is a requisite component of care. For the Pakistani community, given their reluctance to give colostrum to their newborn, this is something that they are disinclined to participate in. It is also perceived that Muslim women are unwilling to expose their bodies.

 

Breastfeeding inequalities are highlighted in the survey Infant Feeding 2000 (Hamlyn et al, 2002) – the latest comprehensive figures available. The next statistics are due next year. From the available data, statistics demonstrate that women who have left school by the age of 16 are less likely to breastfeed than those who continued in education. Only 13% of babies whose mothers were classified in the former group were likely to be receiving any breastmilk by the age of six months. Support for breastfeeding mothers has proved an effective way of helping women to continue – various studies (Littler, 1997; Dykes and Williams, 1999; Ingram et al, 2003; Ahmed et al, 2006) cite the need for such support.

 

Sikorski et al (2004) have undertaken a systematic review on the issue of support (from both the professional and the layperson). There was a beneficial effect on the duration of any breastfeeding with professional support, while lay support positively influenced the duration of exclusive breastfeeding. Dykes and Williams (1999) reported on three areas of support: practical, empathy and approval. While practical support usually came from immediate family or friends, empathy and approval appeared to come from the grandmother. For the latter to occur, the grandmother would usually had to have had a positive breastfeeding experience herself. In Ingram’s study (2003), 93% of Pakistani grandmothers had breastfed. However, negative experiences such as perceived insufficient milk supply, sore nipples and an unsettled infant were likely to have a detrimental effect on the new mother trying to breastfeed her infant. One flaw of support shown in the Dykes and Williams study (1999) was that after the initial two-week postnatal period, most support was withdrawn as relatives left and partners returned to work. Within the Pakistani community it is common to find extended families living together, therefore problems of withdrawal of support should be less evident (Shaw, 1994; Katbamna, 2000). The peer support initiative has proven successful with minority ethnic women in increasing the initiation and duration of breastfeeding (Department of Health, 2003b; Raine, 2003; Ahmed et al, 2006). A recent systematic review by Renfrew et al (2005) also highlights the importance of support, both peer or professional, in encouraging continuation.

 

 Many women have, consciously or not, made a decision regarding their chosen method of infantfeeding well before they become pregnant (Murphy, 1999). However, midwives can make a difference to breastfeeding initiation and continuation rates with those who remain undecided in the antenatal period. Lavender et al (2000) undertook a longitudinal study to ascertain women’s views on information provision during pregnancy. Questionnaires were given to women attending one antenatal clinic over a period of a calendar month. They completed further questionnaires at 20 weeks, in the third trimester, the immediate postnatal period and when they were discharged from the care of the community midwife. Although this was a small study (initially 126 women completed questionnaires, falling to 60 women in the postnatal period), it highlighted aspects of information provision that could be improved. The main finding was that women want information tailored towards their individualneeds. It was suggested that more comprehensive or consistent information be made available at optimal times. Interestingly, women reported information from other sources, such as family, friends and books as being most useful when midwifery input was at its greatest – in the third trimester. Although there is no information about the ethnicity of women who participated in this study, consideration must be given to potential language barriers. Much of the information regarding infant-feeding is transmitted through parent education classes and there is poor attendance from women whose first language is not English and those from lower socioeconomic groups (Horsfall et al, 2003). West and Topping (2000) also highlighted that midwives’ individual experiences with breastfeeding may influence the information they provide, despite written policies being in place. This may be why many women report being given conflicting advice and information.

 

A new approach to supporting breastfeeding has seen the introduction of baby cafés (Williams, 2003). The concept was to provide an environment where breastfeeding was valued and encouraged and provide centres of excellence with regard to help and support. The cafés are usually set up as a weekly drop-in facility in a locally-accessible venue. Finigan (2003) reported that Asian women attending the groups valued evidence-based advice and care particularly where they felt most understood and safe – that is, in their local community.

 

The lack of support from health professionals and others has been identified as influencing the continuation of breastfeeding (Sikorski et al, 2004). Studies by Kong and Lee (2004) and Guttman and Zimmerman (2000) investigated mothers’ views, identifying negative responses to breastfeeding in public. Ingram et al (2003) also highlighted that South Asian women are very private and that even when exclusively breastfeeding in the home, the majority will use bottles of water, formula milk or a dummy when outside. This may be one reason why women in Hartley’s audit (2003) discontinued breastfeeding while still in hospital. Visiting hours have increased considerably over the last 15 years, leaving little time when women are able to breastfeed in private. Even being behind a curtain may not afford the amount of seclusion required.

 

 Discussion

The local audit undertaken by Hartley (2003) indicated low breastfeeding initiation rates in the predominantly Pakistani area investigated. As a result of this, it is hoped that interventions will be put in place to increase breastfeeding rates in line with Department of Health targets (2003a). However, all women must be offered informed choice when making decisions about their care (NMC, 2004). O’Cathain et al (2002: 138) undertook a postal survey of a sample of antenatal and postnatal woman to ascertain if they felt they had exercised informed choice – defined as: ‘Having enough discussion with either midwives or doctors to make choices together about all things that happened in maternity care.’ The postnatal sample comprised 1741 women who were asked specific questions about five decision points, including the decision to breast- or bottle feed – 70% of the sample felt they had exercised informed choice. The perception of having made an informed choice was more apparent in multiparous women and those with lower educational attainment and in manual occupations. It is acknowledged that only a small group (n=26) of women in the overall sample were from an ethnic minority group (their ethnicity was undefined). A total of 50% felt they had exercised informed choice.

 

It is generally accepted that no individual makes a decision in isolation, but in the Pakistani community it is well-documented that decisionmaking usually involves the extended family (Katbamna, 2004). Human behaviour and decision- making is concerned with social psychology and one theory that may explain this is ‘planned behaviour’. This was described by Azjen and Madden (1986) in the terms of a person’s decision as to how they may behave being based on how easy or difficult they perceive that behaviour to be. This reflects factors that are internal (knowledge, skills and will-power) and external (time, availability and cooperation). Kraft et al (2005) hypothesise that most decisions are made on the extent to which a person perceives the behaviour to be under their control. This is relevant to all areas of maternity care.

 

When considering infantfeeding, it indicates that women must first have knowledge of the available options. From the literature review it is clear that many Pakistani women are not aware of the benefits of breastfeeding (Mitra et al, 2004). The cooperation of others is of great significance and health professionals can influence the decisions by being aware of individual clients’ cultural beliefs. Family and friends can influence the initial feeding choice, the duration and continuation of breastfeeding and support to allow time for breastfeeding. Once a decision has been made, the commitment to continue can be explained by the theory of ‘continuation intention’ (Chatzisarantis et al, 2004).

 

This postulates that intentions decline over time as people gradually devalue the outcomes. The authors propose that achievement of behaviour can affect initial motivation. However, if a woman enjoys breastfeeding, this may spur her on to achieve new outcomes such as continuation.

 

Conclusion

From the literature, it is clear that there are many factors that impact on women with regard to breastfeeding. These factors may be compounded for Pakistani women living in a deprived Sure Start area where language barriers exist. They perhaps are not given the opportunity to make an informed choice. When interventions are put in place allowing for open discussion in the woman’s native language, this can improve breastfeeding rates. Leaflets in the correct language are useful to support the discussion and can be used for reference later.

 

Support is a big issue for any breastfeeding mother and health professionals must ensure that they offer culturally-sensitive care. It has been found to be beneficial if the midwife can involve other family members in discussions about infantfeeding, so they are better able to offer support to the new mother.

 

Next steps

Although the literature has highlighted a number of issues, midwives can only supply information tailored to a woman’s needs if they know what those needs are. Summers et al (1997) reported difficulties in access to research involving women from Asian communities. It is emphasised that although the impending study is to include a particular group of women, the problems highlighted will be evident in any group of women who have migrated to another country where language, cultural norms and the process of health care is unfamiliar. Women such as these often live in extreme poverty and it is these hard-to-reach communities that could realise real health benefits from breastfeeding. If something can be learned of the Pakistani women’s feeding intentions and decisions, then any interventions identified as necessary from the findings could potentially be transferable to other minority groups.

 

References

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