UK-born ethnic minority women and their experiences of feeding their newborn infant

Midwifery ] (]]]]) ]]]–]]]

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Midwifery

0266-61

doi:10.1

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E-m1 N2 N

PleasMidw

journal homepage: www.elsevier.com/midw

UK-born ethnic minority women and their experiences of feeding theirnewborn infant

Katherine Twamley, MSc (Research Officer)a,1,n, Shuby Puthussery, PhD (Research Officer)a,2,Seeromanie Harding, PhD (Head of Programme)b, Maurina Baron, GDip (education), MBA, BSc Psy, RM(Lecturer)a, Alison Macfarlane, BA, Dip Stat, CStat, FFPH (Professor of Perinatal Health)a

a Midwifery Department, City University, 20 Bartholomew Close, London EC1A 7QN, UKb Medical Research Council Social and Public Health Sciences Unit, University of Glasgow, UK

a r t i c l e i n f o

Article history:

Received 9 January 2010

Received in revised form

8 June 2010

Accepted 14 June 2010

Keywords:

Breast feeding

UK-born ethnic minority women

Qualitative research

38/$ - see front matter & 2010 Elsevier Ltd. A

016/j.midw.2010.06.016

esponding author. Present address: The So

e of Education, University of London, UK.

ail address: [email protected] (K. Twamley

ow at the Institute of Education, University o

ow at Family & Parenting Institute

e cite this article as: Twamley, K., etifery (2010), doi:10.1016/j.midw.20

a b s t r a c t

Objective: to explore the factors that impact on UK-born ethnic minority women’s experiences of and

decisions around feeding their infant.

Design: in-depth semi-structured interviews.

Participants: 34 UK-born women of Black African, Black Caribbean, Pakistani, Bangladeshi, Indian and

Irish parentage and 30 health-care professionals.

Setting: women and health-care professionals were recruited primarily from hospitals serving large

numbers of ethnic minority women in London and Birmingham.

Findings and conclusions: despite being aware of the benefits of exclusive breast feeding, many women

chose to feed their infant with formula. The main barriers to breast feeding were the perceived

difficulties of breast feeding, a family preference for formula feed, and embarrassment about breast

feeding in front of others. Reports from women of South Asian parentage, particularly those who lived

with an extended family, suggested that their intentions to breast feed were compromised by the

context of their family life. The lack of privacy in these households and grandparental pressure

appeared to be key issues. Unlike other participants, Irish women reported an intention to feed their

infant with formula before giving birth. The key facilitators to breast feeding were the self-confidence

and determination of women and the supportive role of health-care professionals.

Implications for practice: these findings point to common but also culturally specific mechanisms that

may hinder both the initiation and maintenance of breast feeding in UK-born ethnic minority women.

They signal potential benefits from the inclusion of family members in breast-feeding support

programmes.

& 2010 Elsevier Ltd. All rights reserved.

Introduction

The benefits of breast feeding for both mother and infant havebeen well documented. Breast feeding is associated with areduced risk of many diseases in infants and mothers (Ip et al.,2007), including chronic diseases in later life, such as type 2diabetes (Owen et al., 2006). Breast feeding protects againstsevere morbidity in the early years of an infant’s life (Quigleyet al., 2007), and is associated with improved cognitive and motorskills development (Sacker et al., 2006; Kramer et al., 2008). Forthese and many more reasons, the World Health Organization

ll rights reserved.

cial Science Research Unit,

).

f London.

al., UK-born ethnic minorit10.06.016

(WHO) recommends a minimum of six months exclusive breastfeeding for optimum care of the newborn (World HealthOrganization, 2001; Kramer and Kakuma, 2004). Policies tosupport breast feeding have been implemented to encouragemore breast feeding in the UK (Department of Health, 1993, 2004;Dyson et al., 2006; National Institute for Health and ClinicalExcellence, 2006). These have included implementation of theBaby Friendly Initiative developed by the United Nations Inter-national Children’s Education Fund (UNICEF) and WHO.

Infant feeding has been monitored through five-yearly surveysin the UK. The most recent data from 2005 show that breast-feeding rates have increased but are still low; 76% of mothers inthe UK initiated breast feeding at birth but only 25% were stillbreast feeding at six months, 7% exclusively (Bolling et al., 2007).Among the general population, first-time mothers are more likelyto breast feed and rates are higher among older women andwomen in professional or managerial socio-economic groups

y women and their experiences of feeding their newborn infant.

K. Twamley et al. / Midwifery ] (]]]]) ]]]–]]]2

(Bolling et al., 2007). The association of socio-economic statuswith breast feeding amongst non-White women is less clear(Griffiths et al., 2007). Educated non-White women are morelikely than those with minimal qualifications to continue breastfeeding but are also more likely to introduce solids earlier(Griffiths et al., 2007).

Rates of breast-feeding initiation are higher amongst BlackCaribbean, Black African and South Asian women than amongstWhite English women (Griffiths et al., 2005; Kelly et al., 2006;Bolling et al., 2007). Black and South Asian women are also morelikely to sustain breast feeding for longer (Kelly et al., 2006), butdifferences in exclusive breast feeding are smaller (Thomas andAvery, 1997; Bolling et al., 2007). Mixed feeding (combiningbreast and artificial milk) is not as beneficial as exclusive breastfeeding and inhibits the milk production in the breast, encoura-ging earlier transfer to exclusive formula feeding (Foster et al.,1997). There are no data about breast-feeding rates of Irishwomen in Britain.

Exclusive breast-feeding rates for less than six months in thehome countries from which UK ethnic minority women originateare higher than in the UK, for example: 46% in India, 37% inPakistan, 43% in Bangladesh, 15% in Jamaica, 12% in Nigeria and54% in Ghana (World Health Organization, 2001). NorthernIreland has the lowest rate of breast feeding in the UK (63%initiate compared with 78% in England) (Bolling et al., 2007), andthe Irish Republic (43% initiate) has the lowest breast-feeding rateof those recorded in Europe (Euro-PERISTAT, 2008).

Few studies in the UK have differentiated between experiencesof migrant and UK-born ethnic minority women. Recent evidencesuggests an erosion of the breast-feeding advantage in ethnicminority mothers born in the UK; UK-born Black and South Asianwomen are less likely than migrant women to initiate breastfeeding and to breast feed for at least four months (Hawkins et al.,2008). There are similar findings in the USA amongst Hispanic andBlack women (Singh et al., 2003; Tolbert Kimbro et al., 2008).

Research which explores the processes through which ethnicminority women make their decisions about breast feeding islacking. Some studies of South Asian women have reported onissues related to perceived ‘impurity’ (Shaw et al., 2003; Spiro,2007) or ‘inadequacy’ of colostrum (Littler, 1997). Anecdotalevidence suggests that South Asian grandmothers encourage theintroduction of formula feed (Ingram et al., 2003). A historicalliterature review reported ‘prudishness’, embarrassment andpoorer socio-economic circumstances as possible reasons forlow rates of breast feeding amongst Irish women (Ineichen et al.,1997). Although this study concentrates on ethnicity as anexplanatory variable, a non-essentialist approach has been taken;i.e. it is understood; that the strength of ethnicity as a mediator isdependent upon other situational factors (Baumann, 1996).

Supportive factors for prolonged breast feeding include amother being breast fed herself, having peers who breast feed(Meyerink and Marquis, 2002) and having sympathetic kin(Bryant, 1982). Practical and technical support from health-carestaff, such as positioning of the infant on the breast (Renfrew,1989; Graffy and Taylor, 2005; Merewood et al., 2006; Brittonet al., 2007) and social and emotional support (Scott and Mostyn,2003; Graffy and Taylor, 2005) are also beneficial.

Methods

In-depth semi-structured interviews were conducted with34 UK-born women of Pakistani, Indian, Black Caribbean, BlackAfrican, Bangladeshi and Irish parentage who had recently givenbirth. The interviews were conducted with the women alone in theirhomes, except for one interview which was conducted in a hotel.

Please cite this article as: Twamley, K., et al., UK-born ethnic minoritMidwifery (2010), doi:10.1016/j.midw.2010.06.016

The topic guide was informed by the previous interviews conductedwith 30 health-care professionals, primarily midwives. The topicswere broadly similar between the two groups, covering pregnancy,birth, caring for the newborn, infant feeding, and family and partnerinvolvement in decisions around care. Infant feeding emerged as amajor issue of concern for both women participants and the health-care professionals that care for them. All interviews were recordedand transcribed after written consent had been obtained.

Analysis of interviews was based on methods from thegrounded theory approach (Glaser and Strauss, 1967), whichallows views to emerge from the data (Glaser, 1992). The first stageof analysis involved immersion in the data through reading andre-reading the interview transcripts. Codes were attached on a line-by-line basis, reflecting their meaning or key message. Codes werethen grouped into broader categories where it was thought therewas a connection or similar message from the data. In particular,the constant comparative method was useful in exploring the data;data from different individuals were compared and questions wereasked of emerging concepts, constantly refining and reworking theunderstanding of the data. Analysis of interviews with the health-care professionals and the women fed into one another. Thesoftware package NVIVO was used to facilitate this process. Fourmembers of the research steering group took part in preliminarycoding in order to validate the labelling of codes and broadercategories (Barbour, 2001). A full description of the ‘Born in the UKStudy’ can be found elsewhere (Puthussery et al., 2008b). Ethicsapproval was obtained from the South East Multicentre EthicsCommittees and the relevant National Health Service trust researchand development committees.

Sample

The 34 women of ethnic minority background were recruitedprimarily by midwives in nine maternity health clinics located inareas with large numbers of ethnic minority women in Londonand Birmingham. Full details of the recruitment procedures arereported elsewhere (Twamley et al., 2009). Demographic details,including ethnicity, were collected through a recruitment formfilled in by the participants themselves. The majority werewomen of Black Caribbean or Indian origin (Table 1), as theauthors were most successful at recruiting women from thesebackgrounds. Black Caribbean women reported lower levels ofeducational attainment; the majority were educated until 16years of age or less, whereas most Indian women reported havinga university degree.

For each woman quoted below, ethnicity, age group, educa-tion, primiparous/multiparous and reported breast-feeding prac-tices are described. ‘GCSE’ refers to General Certificate ofSecondary Education – a state examination taken at 16 years ofage in England and Wales. ‘A-level’ refers to a state examinationtaken at 18 years of age. Some women cited as ‘exclusively breastfeeding’ gave occasional formula feeds, for example whenseparated from the infant for a few days. Women cited as ‘mixedfeeding’ gave formula feeds regularly, usually formula feedsduring the day and breast feeding at night. Some women wereinterviewed before six months, in which case their feedingintentions up until six months are reported. Women whoseparents originated from South Asia (India, Pakistan and Bangla-desh) are sometimes reported together due to the similarity oftheir experiences.

Health-care professionals interviewed included 18 midwives,five obstetricians, two general practitioners and five other health-care professionals involved in maternity care. Over half camefrom an ethnic minority background (see Puthussery et al.,2008a).

y women and their experiences of feeding their newborn infant.

Table 1Socio demographic profile and breast-feeding duration of participating women by ethnic group.

Indian Pakistani Bangladeshi Black Caribbean Black African Irish All

All 11 4 2 10 2 5 34

Mother’s age, yearso20 0 0 0 2 0 0 220–29 5 2 2 2 1 0 1230–39 6 2 0 4 1 5 1840+ 0 0 0 2 0 0 2

Educational levelDegree or above 9 4 0 1 2 1 17A-level 1 0 1 2 0 1 5GCSE or below 1 0 1 7 0 3 12

Breast-feeding durationArtificial milk feeding introduced in first 48 h 1 1 1 1 1 1 6o6 monthsa 5 1 0 5 0 3 146 months+a 5 2 1 4 1 1 14

a Mixed and exclusive reported together.

K. Twamley et al. / Midwifery ] (]]]]) ]]]–]]] 3

Findings

Women appeared to be aware of the health benefits of breastfeeding; many spoke of antibodies being transferred to the infantthrough breast milk and of reduced chances of breast cancer forthe mother. They learnt about the benefits from midwives,posters, friends and family, and child care literature. Still, theirinterviews dwelt at length on the barriers to breast feeding.These included the difficulties of breast feeding, a familypreference for formula feeding and embarrassment about breastfeeding in front of others. Health-care professionals felt that SouthAsian women also avoided giving colostrum. The key facilitatorwas the level of commitment to breast feeding. Self-confidence ofwomen and the supportive role of health-care professionals werealso important.

Barriers to breast feeding

Breast feeding as interruption or chore

One of the main barriers to breast feeding felt by womenacross the ethnic groups was a perception of breast feeding astime consuming in comparison to bottle feeding. Women citedlengthy hours spent breast feeding, the sleepless nights beforeintroducing formula feed, breast feeding restricting movementoutside the house without the infant, and the inability to carry outhousehold tasks whilst breast feeding:

I went to my friend’s house once for the afternoon and she wason me for about four hours constantly, and it’s just too much. Ican’t sit and do that every day. (Black Caribbean, 40+ years,GCSE or below, multiparous, mixed fed three months)

I mean, I wanted to breast feed, I did, I definitely wanted tobreast feed, but it just took too long. (Black Caribbean, 30–39years, degree, primiparous, breast fed three months)

South Asian women living with extended family tended toview feeding as a task which other family members could assistwith by giving formula to their infant:

Like ‘cause I’ve got, you know I’ve got mum and dad, mum’snot well either, she’s on dialysis, so she’s not a well person andthen I’m always running around you see and I had him and I’ve

Please cite this article as: Twamley, K., et al., UK-born ethnic minoritMidwifery (2010), doi:10.1016/j.midw.2010.06.016

got granddad who’s 90 years old upstairs so there’s always like.y And then I started [giving formula feed], at least that waymum and dad can feed him as well. (Indian, 20–29 years, GCSEor below, primiparous, breast fed five weeks)

Then I couldn’t really fit it in with the housework and stuff, it’slike even sitting down for like ten minutes, I used to think, ohmy God I could have got that done and I could have got thatdone [y] and then I just put her on the bottle. y At least withbottle feeding, you can like make the milk or you know tell mymother-in-law you feed the baby. (Pakistani, 20–29 years,degree, multiparous, breast fed one week)

Women mentioned family members and husbands feeling‘relieved’ at the switch to formula feeding so they could ‘pitch in’with the care of the newborn. This was recognised by the health-care professionals who expressed disappointment and frustra-tion:

The mother-in-laws will take over the care of the babies, whichis when breast-feeding falls down, because the mother-in-lawcan give the baby a bottle while the mother is getting on withher chores. And I find that very, very difficult to accept. (Linkworker, female, Bengali)

Grandparents’ preference for formula feeding

South Asian women, particularly those who lived with anextended family (nine out of 16 South Asian participants),reported pressure from parents and in-laws to introduce formulato their infant. For some women, this pressure led to the earlyintroduction of formula and feelings of inadequacy and failure:

I think one day I went out and my mother tried to force feedhim formula milk, because my nephew has formula milk. He’sa month apart and so my sister-in-law told me ‘I had nothingto do with it! Your mum tried to force him to have formula’.(Pakistani, 30–39 years, degree, multiparous, breast fed sixmonths)

I was very set about it, I said to myself, no I’m not giving her abottle no matter what and then it got to one point where,when I can’t remember what had happened, but it was soupsetting, I said to him [husband], do you know what, just giveher a bottle because I’m getting upset and if I’m upset then I

y women and their experiences of feeding their newborn infant.

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can’t feed her properly, so she’s getting upset, so just give her abottle. It got to that point. That’s how bad it got.

(Indian, 20–29 years, degree, primiparous, breast fed threemonths)

[There were] constant fights. y they’re always pushing you,and it’s almost like they’re pushing you not to breast feed,they’re pushing you to top up all the time, all the time.

[Indian, 30–39 years, degree, primiparous, intention to breastfeed for six months (interview at four months)]

Two Indian women described suffering from mental healthdifficulties due to this pressure, as this extract from one woman’sinterview shows:

I mean, it’s hard to say, but, you know, postnatal depression,it’s not like a cold that you can sit there and say, well yeah,actually I had postnatal depression. Is that, you know, therewas times I was really down and there was times I’ve got reallyemotional and everything and that was a large part, as I said,due to the, sort of, influences in family and the pressures of,like, breast feeding, bottle-feeding, that really, really did get tome. (Indian, 20–29 years, degree, primiparous, breast fed fiveweeks)

Some women were able to withstand the pressure to giveformula feed; these tended to be more educated women or thosewho did not live with their in-laws:

She [mother-in-law] was going ‘Oh, you should give him thebottle’ and I was like, ‘No, I don’t want to’ and the more shesaid ‘give him the bottle’, the more I was like ‘No, I’m not goingto give him that. I want to do what’s going to be best for him’.(Indian, 30–39 years, degree, primiparous, breast fed 5.5months)

I think also probably because I’m a doctor, sometimes she’d tellme things, I’d say mum I don’t think so, then she’d just kind oflaugh and say, all right, and she’ll listen to me. Whereas I thinkwith my sister, she wasn’t. You know, she’d try and tell her, noyou must do it this way, you must do it that way. (Indian/Pakistani, 30–39 years, degree, multiparous, breast fed sixmonths)

Health-care professionals felt that education made a bigdifference in being able to ‘stand up to the in-laws’ (seePuthussery et al., 2008a for further discussion).

The main reason that parents and in-laws suggestedformula feeding appeared to stem from the belief that breastmilk is not enough to feed a newborn infant. As one womanrecounts:

I think in our culture as well we think that we’re not goingto make enough milk, for a boy especially, because a boy willneed more food then a girl and may be hungry so give thema bottle. (Indian, 30–39 years, degree, primiparous, breast fed5.5 months)

Parents and in-laws felt vindicated when a switch to formulafeeding resulted in longer sleeping hours for the infant, ‘proving’that the infant had been better fed by the formula. Other Indianwomen reported no pressure from parents or in-laws, but some ofthese agreed that breast milk was not sufficient to ‘fill up’ theinfant:

I used to breast feed him and introduce the bottle to him aswell, so if I didn’t have enough for him I used to top him upwith a bottle, and that’s only if I had to. (Indian, 30–39 years,A-level, primiparous, breast fed four weeks)

Please cite this article as: Twamley, K., et al., UK-born ethnic minoritMidwifery (2010), doi:10.1016/j.midw.2010.06.016

SP: So exclusive breast feeding was for like three weeks?

R: Not exclusive to be honest. As I say, because she wasn’t

filling with what I was giving, what I was producing.

(Indian, 20–29 years, degree, primiparous, mixed fed threeweeks)

Health-care professionals expressed the view that ‘topping up’with artificial milk was a preference common among South Asianand African families. Not all of the South Asian womeninterviewed preferred to or experienced pressure to ‘top up’though, and it was not a perception shared by the two Africanwomen interviewed:

Some African women will always mix feed because that’s theway they do things and they will continue and they willencourage their young people to do that, so. [Communitymidwife 2, female, White British (years of service unknown)]

The [African] mothers are always telling them to mix-feedbecause they have this insight thaty I don’t know whether itis to do with how they grew up like they were living in povertyin their home country or what but a big baby seems to be morehealthy, a sign of health. Big and healthy so they feel that justthe breast milk is not enough therefore they have to giveformula milk as well to make the babies a bit bigger. y They[y] have a bit of difficulties trying to tell their parents ‘no, justbreastfeeding is fine you don’t have to mix-feed as well’.[Community midwife 1, female, Black Caribbean (17 years ofservice)]

I mean she was on breast milk only and now if you comparewith other babies! I’m thinking ‘ooh, okay that’s a bit small’ ormaybe the skin is not as glowy as she is [indicates daughter].So like I said, the immunity helps her too. (Black African, 30–39years, degree, primiparous, breast fed six months)

Amongst the Irish women, there was some evidence of parentsencouraging artificial milk feeding, but this was not expressed as‘pressure’ or ‘difficult’ as in the case of the South Asian women. Allbut one of the Irish participants felt that artificial milk feedingwas the better option. In particular, unlike other participants, Irishwomen reported an intention to feed their infant with artificialmilk even before giving birth:

But, yeah, I just assumed it would be, but I kind of knew fromother people that they always mix feed, that their baby was toohungry, so I assumed, you know. y , I just wouldn’t do itmyself, I would feel far too self-conscious and to be honest Idon’t really want to sit and look at somebody doing it either, intruth. (Irish, 30–39 years, A-level, primiparous, breast fed twoweeks)

Talking to my cousins and that, I think they’re all very muchthe same, sort of, oh well, you know, you don’t need to botherwith all that breast-feeding lark /laughsS, the bottle will befine and it was, yeah. (Irish, 30–39 years, GCSE or below,primiparous, breast fed three weeks)

Embarrassment at breast feeding in public

Health-care professionals felt that embarrassment to breastfeed in the presence of other people was particularly common inSouth Asian Muslim women, and thus made it difficult to helpthem:

If you’re helping them to breast feed, they’re quite happy foryou to do whatever you need to do to help them to position the

y women and their experiences of feeding their newborn infant.

K. Twamley et al. / Midwifery ] (]]]]) ]]]–]]] 5

baby, latch the baby on. But if somebody else comes in theroom, they’ll quite often cover themselves back up. It’s alrightfor you to be in there with them, but if somebody else walks in,whoever it may bey the shawl will come ony whether it’sanother female y and that is second generation. [Communitymidwife 2, female, White British (two years of service)]

Embarrassment at breast feeding in front of others wasexpressed by many of the participants from all ethnic back-grounds, noting that ‘this country is not geared up for breastfeeding’. Some felt embarrassment within their home as relativescame to visit, particularly Irish and South Asian women. Otherswere more anxious about breast feeding in public places. To avoidembarrassment, women reported using infant feeding facilities, ashawl or hijab, and sometimes giving artificial milk:

I found it quite hard, telling you the truth, because I’m livingwith family and it’s like the main house, all of our cousins andeverything come here and I found it quite a bit embarrassing aswell when people used to come, like my brother-in-laws in theroom or something like that. (Pakistani, 20–29 years, degree,multiparous, breast fed one week)

I’m breast feeding. He’s only had a bit of formula anyway, ifwe’re going out and I can’t breast feed. Otherwise I’ll take someformula milk just in case but I try and go somewhere, if I amgoing into the city centre, that ywhere that has a baby feedingfacility where I breast feed him ywhich is probably onlyMothercare.

Black Caribbean, 30–39 years, GCSE or below, primiparous,breast fed three months (intending to introduce artificial milkfeed soon after interview)

KT: So how do you feel about breast feeding in public? Isthat a problem?

R: Erm y it isn’t normally because I’m covered upnormally and I normally have my shawl and my hijabwhen I’m out and about as well. I tend to do it so thatyou stay covered and everything’s covered up.

(Pakistani, 30–39 years, degree, multiparous, breast fed sixmonths)

Colostrum

Health-care professionals were concerned about the delay inthe initiation of breast feeding among South Asian womenbecause of the perceived cultural tradition of not giving colostrumin the first few days:

For some of the women fromywhose background would be fromthat part of the world [South Asia], we could have the situationwhere they don’t give colostrum to their babies in the first fewdays so we’ll have missed a huge opportunity to help them whilethey’re here. [Breast-feeding councellor, female, Irish (33 years ofservice)]

So educating them to start breast feeding from birth, that is abig job as well but that’s what we’ve been trying to do, becauseone of the myths is the first three days the milk, you know thecolostrum? That is not good. That’s supposed to be ‘unclean’.[Link worker, female, Bengali (years of service unknown)]

These views, however, were not borne out in the interviewswith the women. All of the South Asian women interviewedreported initiating breast feeding within the first few hours, andthey did not express any concerns about giving colostrum.

Please cite this article as: Twamley, K., et al., UK-born ethnic minoritMidwifery (2010), doi:10.1016/j.midw.2010.06.016

Facilitating factors for breast feeding

Commitment and self-confidence

Women who maintained prolonged and, on the whole,exclusive breast feeding used strong language of determinationwhen they spoke of their experiences of breast feeding:

And when you start there’s always a few problems so it washard, I have to admit. I had sore breasts and sore nipples so Iwas like ‘ooh, this is y no one told me it was going to hurt thismuch!’ But you just have to push through it, and because I wasquite stubborn, I was quite determined to do it. (Indian, 30–39years, degree, primiparous, breast fed 5.5 months)

Well it’s the best thing for your baby, really, so I just decidedyI wouldn’t ideally want to do it because I don’t like the thoughtof it but I know it’s the best thing for my baby, it’s gotantibodies and it’s everything he needs in it. And it’s easy aswell at the end of the day, you don’t need to think aboutsterilising bottles and making up feeds and the rest of it.(Indian, 30–39 years, degree, primiparous, breast fed sixmonths)

He’s fine, I mean weight-wise he’s fine. He’s going up on thegraph. y I’m not worried about him not having enough milkor anything. (Pakistani, 30–39 years, degree, multiparous,breast fed six months)

These women tended to come from more educated back-grounds and were confident in dispelling ‘myths’ about breastmilk not being enough. The main motivation reported was thehealth of the infant, and some viewed breast feeding as ‘lesshassle’ than formula feeding. Some of these women appeared tohave good support from husbands, family and friends; those thatdid not, reported going to great lengths to access professionalsupport – attending breast-feeding support groups or visitingbreast-feeding counsellors. For example, the Pakistani womanquoted above set up a breast-feeding group for Muslim women inher area.

Support from health-care professionals

Women from all ethnic backgrounds described high levels ofdissatisfaction with maternity care services, and in particular thepostnatal care ward (Puthussery et al., 2008b), but felt that whenhelp to breast feed was given, it was extremely valuable:

Even when I had to breast feed, they didn’t show it to meproperly, that’s why I got, I had bloody, my nipples got verysore. The hospital didn’t show me how to do it properly. yThen when I came home it just went worse and my breast gotreally sore, so you know, I gave her a bottle as well. y It’s onlynow I’ve got home and asked the local GP midwife, her waywas the best way because ever since that’s the way I’ve beendoing it and she sucks properly. (Black African, 20–29 years,degree, primiparous, mixed fed)

She [breast-feeding counsellor] did talk to me about it, helpedme, showed them how to latch on properly. She was very good.And then yeah, it was fine. (Indian, 30–39 years, degree,multiparous, breast fed nine months)

Women felt that they needed reassurance from the health-careprofessionals that they were breast feeding ‘right’ and that the

y women and their experiences of feeding their newborn infant.

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infant was getting sufficient milk:

I wasn’t sure if he was feeding and then he’d be going like this,but you don’t know if he was taking any milk, you know. (BlackCaribbean, 30–39 years, degree, primiparous, breast fed threemonths)

I’m concerned about how much she’s getting, and I justthought ‘oh, I can’t do this’. (Black Caribbean, 40+ years, GCSEor below, multiparous, mixed fed three months)

And I could never know how much he’s fed or, that’s the thingwith breast feedingy (Indian, 20–29 years, GCSE or below,primiparous, breast fed five weeks)

As one woman said:

It’s just about building up my confidence. (Black Caribbean,o20 years, GCSE or below, primiparous, breast fed five weeks).

Women who faced pressure from parents or in-laws to giveformula feed felt that midwives and health visitors could play afacilitating role by reassuring the family about the value of breastfeeding:

I asked her ‘look can you just explain to her, in front of mymum, that she’s doing fine with the breast feeding and just puther at ease as well?’ And she said ‘look you’re doing fine, you’redoing just fine, you’re breast feeding perfectly, she’s latchingon well, she’s getting full up, don’t worry about it’ and that wasquite promising as well. (Indian, 20–29 years, degree,primiparous, breast fed three months)

I mean, I know I didn’t keep it up for very long, you know, itwas only a month, but it wouldn’t have even been a month, Ithink I would’ve just given up after, sort of like, sort of, dayone, because the pressure. y And it was the constantreassurance that I got from the midwife that made me think,no, actually, you know what, I am determined, y ‘cause I thinkI would’ve given up breast feeding a lot earlier if it wasn’t for,just the constant reassurance of, no, no, no, you know whatyou’re doing, it’s good. (Indian, 20–29 years, degree, primipar-ous, breast fed five weeks)

Discussion

Women participants were generally aware of the healthbenefits of breast feeding, but some women were very deter-mined to breast feed while others appeared to prefer to giveformula feed. This concurs with previous research, which suggeststhat knowledge of the health benefits of breast feeding does notnecessarily result in sustained breast feeding (Hally et al., 1984;Hoddinott and Pill, 1999).

Commitment and intention to breast feed emerged as a keyfactor in enabling longer periods of breast feeding; women withhigh levels of commitment persevered in spite of the difficultiesthey experienced (Cox and Turnbull, 1994; Lawson and Tulloch,1995; Duckett et al., 1998; Whelan and Lupton, 1998; Hoddinottand Pill, 1999; Scott and Mostyn, 2003). Some UK-born SouthAsian mothers in this study reported an intention to breast feedbut their confidence and ability to breast feed appeared to becompromised by their family life, particularly for those living withor near to their in-laws. The lack of privacy in these householdsand grandparental pressure appeared to be key issues. Grand-mothers were not interviewed in this study so it is difficultto understand why women who have come from countrieswith relatively high rates of exclusive breast feeding are now

Please cite this article as: Twamley, K., et al., UK-born ethnic minoritMidwifery (2010), doi:10.1016/j.midw.2010.06.016

encouraging their daughters to give formula feed. There is someevidence, however, that exclusive breast-feeding rates aredecreasing in these same countries; evidence from India, forexample, suggests that a lack of family support and a perceptionof inadequate breast milk supply is reducing exclusive breastfeeding there, possibly fuelled by aggressive promotion of formulafeed (Gupta and Gupta, 2004; Indian National Family HealthSurvey, 2006). Furthermore, these grandmothers will have givenbirth in the UK at a time when breast feeding was less promotedin UK hospitals and formula advertising was less restricted. Onecan only speculate. At any rate, these findings suggest that furtherresearch into grandparents’ attitudes to and influence over theirdaughters’ breast-feeding practices is merited.

Other women felt that the benefits of artificial milk feedingoutweighed those of breast feeding. In this study, these womenappeared to have a particular concern about the ways in whichbreast feeding disrupted their lives, and viewed breast feeding asone amongst many other tasks (Schmied and Lupton, 2001;Dykes, 2005). An ethnographic study of women initiating breastfeeding in a postnatal care ward found that women ‘conceptua-lised breastfeeding as a ‘productive’ project, yet expressed deepmistrust in the efficacy of their bodies’ (Dykes, 2005, p. 2283).That is women tended to concentrate on the production ofnutrition for their babies, rather than valuing the process of breastfeeding, such as the relationship and bonding which breastfeeding can facilitate. Concentration on the productive aspect ofbreast feeding can encourage feelings of frustration and impa-tience at the slow production of milk, whereas artificial milk canbe easily ‘produced’ by other family members.

The Irish women interviewed in this study expressed adisinterest in breast feeding, with most reporting intentions tomix or to give formula feed, even before giving birth. Intention tobreast feed is strongly related to successful breast feeding(Hoddinott and Pill, 1999). These findings should be judgedtentatively since the sample size was so small and the Irishwomen in the sample had lower levels of education, usuallynegatively associated with breast feeding (Bolling et al., 2007).Nonetheless, research in Ireland has suggested a ‘cultural’ barrierto breast feeding there (Tarrant and Kearney, 2008). Furtherresearch on the decision-making processes of British women ofIrish decent is warranted.

Overall, health-care professionals’ impressions of the barriersto breast feeding were in line with the views expressed bythe women, except in relation to colostrum. Still, womeninterviewed expressed a desire for more technical and emotionalsupport, and many felt that this was lacking in the postnatal careward. This is part of the wider dissatisfaction with postnatal carein the UK which has been reported elsewhere (Audit Commission,1997; Bick et al., 2001; Baxter, 2006; Redshaw et al., 2006;Twamley et al., 2006).

There are limitations to this study. The number of participantswas small for some ethnic groups. There was also a bias in thesocio-economic make-up of the groups; the Black Caribbean andIrish women were broadly from a lower socio-economic group,and the Indian women were primarily from a higher socio-economic group. The interviews were undertaken between threeand nine months after giving birth, which may have affected somewomen’s ability to recall decisions around breast feeding. A socialdesirability bias may also have encouraged some women todistort some details around breast feeding.

Implications for clinical practice and policy

These findings reflect many of the issues found aroundbreast feeding amongst the general UK or other populations.

y women and their experiences of feeding their newborn infant.

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Nonetheless, the findings point to some culturally specific mechan-isms that may hinder both the initiation and maintenance of breastfeeding in UK-born ethnic minority women. Due to the smallsample size, these should be interpreted with caution but they dosuggest questions for further research in this area. In particular, theIrish women interviewed appeared to be averse to breast feeding,and some South Asian women described a family context whichcompromised their ability to continue breast feeding. The findingssuggest a need to explore family members’ influence over women’sbreast-feeding practice, and possible approaches to including themin breast-feeding promotion and support.

Acknowledgements

The authors would like to thank Shamoly Ahmed, JudithMirskey, Carol Dossett and the former staff of the MaternityAlliance especially Christine Gowdridge, Ruba Sivagnanum, RosBragg and Mary Makoni, and the staff and managementcommittee at Women’s Health and Family Services especiallyJoyce Grandison and Pam Shickler for their support. The authorswould also like to thank all of our participants for giving theirtime and energy to this project. The project was funded by theCommunity Fund, now known as the Big Lottery.

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