In this meta-ethnographic study we have synthesised the findings of 11 studies reporting qualitative data on the breastfeeding experiences and practices of migrant and refugee women now living in a high income, English speaking host country. The overarching theme, ‘Breastfeeding in a new country: contradictions and conflict’, represented not only a clash between an individual woman’s beliefs and practices and the dominant practices in the new country, but also a tension with family members either in the country of origin or in the new country. This conflict is at times exacerbated by a woman’s own expectations as a mother and her material circumstances [43
Breast milk and breastfeeding were afforded high status by women from diverse cultures, with only two studies finding some women perceived formula milk to be equivalent to breast milk. This is reflected in the higher breastfeeding initiation and duration rates amongst migrant women compared to native born women in high income countries [5
]. Only four studies included beliefs about colostrum and for the most part these were positive, contradicting a common assumption among health professionals that many women from ‘Asia’ do not offer colostrum [20
]. Although some participants provided reasons for why they or other women may decide to feed with formula, overall, there was a view that ‘breast is best’ and that breastfeeding is the ‘natural way’ to feed a baby. It is interesting to note that we excluded a number of papers from this synthesis because they did not report substantial qualitative data related to breastfeeding [52
]. We suggest that one explanation for the limited data on breastfeeding in these infant feeding studies may be because participants indicated there was little to discuss as breastfeeding was ‘what you do’, they planned to do it, thought it was best for the baby and did not elaborate during interviews with the researchers [53
It appears that participants from a range of cultural backgrounds living in the UK were less positive towards breastfeeding, for example, the women from Pakistan who participated in Choudhry and Wallace’s study. Similar views reflecting negative attitudes towards breastfeeding in western cultures have been reported among Chinese and Vietnamese women in Australia and Ireland, with some seeing breastfeeding as inconvenient, embarrassing and leading to dependency in the child [10
Despite the positive view of breastfeeding and the importance of breast milk for infants, the research findings suggest that migrant and refugee women can struggle to continue breastfeeding while managing life with a new baby in a new country. Some migrant and refugee women will be poorly resourced, have to return early to paid work, speak little English, and have responsibility to maintain the house without their mothers, mothers-in-law and other family members to support them. In these circumstances, some women indicated that it was best not to even start breastfeeding [25
], particularly if important postpartum cultural practices that maintain health and energy cannot be adhered to.
Most of the studies reported on the importance of a variety of postpartum rituals for the adequate production of breast milk. Groleau et al. argue that the ritualised exposure of mothers to heating and other practices are ‘the cornerstone of a rite of passage to motherhood, a key moment for primiparas to acquire their new identity as mothers’ [43
], p. 520]. If a woman wishes to maintain these practices but is unable to, she may become anxious about her ability to produce sufficient milk. This is more likely to result in cessation of breastfeeding [13
]. This is not because the woman does not value breast milk, rather, as Groleau and colleagues suggest, it is her own milk that she does not consider of high value [43
]. The concept of insufficient milk is also common in western cultures [55
] with many studies exposing the profound mistrust that women have in their bodies and the lack of confidence in their capacity to breastfeed [57
The majority of included studies did not examine differences in breastfeeding practices between women who were recent arrivals and those who had lived in the host country for many years. There were two exceptions [14
]; Choudhry and Wallace found that women who had low levels of acculturation 'were not influenced by the new culture they were living in, and continued to breastfeed their infants as directed by South Asian cultural teachings about the psychological benefits of breastfeeding' [14
], p. 82]. When these women did opt to formula feed, it was in response to conflict they experienced either between the information they received about the best form of feeding or between their roles as a mother and daughter-in-law. Opting to formula feed was a way to resolve the conflict [14
]. These experiences are reflected in some studies of the impact of acculturation. A large cohort study in the US reported that for every year that a migrant woman lived in the US, her odds of breastfeeding declined by 4% and, her odds of doing so for at least six months, declined by 3% [16
In contrast, Grewal, Bhagat and Balneaves [52
] report on an apparent resurgence in second and third generation Punjabi families living in Canada assuming traditional practices related to birth and parenting. Together with Groleau and colleagues, Grewal, Bhagat and Balneaves [52
] caution against the blind acceptance of the acculturation hypothesis and warn health professionals not to make assumptions about perinatal preferences based on time since immigration. Furthermore, Groleau, Soulière and Kirmayer. [43
], p. 542] argue that ‘the acculturation thesis emphasises the role of the host culture in influencing practices but does not pay any regard to women's agency.’ They believe that beliefs and practices linked to breast milk are dependent on, and embedded in everyday cultural practices. This cultural knowledge is ‘maintained and expressed not only through explicit knowledge or beliefs but also in practices that depend on a specific configuration of social space' [43
], p. 524] that is, the everyday living circumstances of women.
The final sub-theme reflects the central place of female family members in the lives of new mothers. Female family members who are available to assist a new mother to participate in the traditional postpartum practices of their native countries were considered by migrant mothers to be important in the maintenance of breastfeeding. Alternatively, through migration or refugee status, some new mothers lacked family support [43
] or the support offered by family members led to conflict and tension [14
], increasing the likelihood that the new mother would cease breastfeeding. For example, in the study by Choudhry and Wallace [14
], some women reported that their role as a daughter in law, and the associated expectations, meant that it was difficult to accommodate breastfeeding in her life as a mother. A recent population based study of the feeding practices of migrant women in the US found that their parents’ country of birth was a significant predictor of breastfeeding initiation and duration [7
]. This highlights not only the importance of understanding the cultural beliefs and practices of new mothers but also those of their mothers and mothers-in-law.
In the absence of a supportive network, women may turn to health professionals for advice. Few of the 11 included studies reported on women’s experiences with health services and health professionals and what was reported tended to be negative. Other studies have reported the barriers that migrant and refugee women experience when seeking services, including language barriers, experiences of discrimination, and conflicting belief systems [52
]. It also appears that some health professionals report it is easier to provide care to women from ethnic minorities born in the host country rather than recently arrived migrant women, citing language barriers as a significant impediment [35
]. Research conducted by McFadden, Renfrew and Atkin [34
] revealed a level of apathy amongst maternity care professionals towards supporting migrant women with breastfeeding. This apathy was fuelled by the belief that migrant women disregarded professional advice in favour of the advice from family, especially grandmothers. The dominant assumption amongst a majority of health professionals was that migrant women were too ‘submissive’ to the influence of their family [34
]. We argue, along with Puthussery et al., [35
] that incorrect assumptions and stereotyping by maternity care providers can lead to attitudes and behaviours that reflect subtle forms of ‘institutionalised racism’ which require innovative intervention strategies to overcome.
The findings of this meta-ethnographic study are limited by the nature and depth of data collection and analysis in each study. As discussed, most studies were descriptive in nature, and did not identify metaphorical statements in their original work. This made it difficult to conduct reciprocal translation. To facilitate the synthesis we adopted the approach described by Atkins [46
] working with first order constructs presented in the papers.
It is also important to emphasise that in this meta-ethnography we have synthesised studies reporting the experiences of women who come from diverse cultural backgrounds and it is inappropriate to attempt to create one picture of migrant and refugee women's breastfeeding experiences and practices. We also note that there are inconsistencies in the approach and terminology used in the original papers when identifying and categorising the ethnicity or cultural background of participants. In some studies, the ethnic background of participants was only identified by country of birth [13
]. Alternatively, some researchers asked participants to identify their ethnic or cultural background when completing a demographic questionnaire but it is not clear if these were open ended or pre categorised responses [25
]. Two studies [14
] explicitly stated that women were asked to self identify their cultural background or ethnicity. Others made no mention of how these details were obtained [30
]. Commentators have emphasised the complexity of assigning ethnicity to study participants [40
] indicating a preference for the value of self assigned ethnicity, although recognising that this adds a level of complexity to data collection and interpretation. This complexity often results in researchers using inappropriate labels to describe cultural background. For example, the terms Asian and South Asian were used in a number of papers to describe people from the Indian sub-continent, many of whom, if asked, would vary in how they described their ethnic identity.