BREASTFEEDING MEDICINE Volume 9, Number 4, 2014 ª Mary Ann Liebert, Inc. DOI: 10.1089/bfm.2013.0129
At the Edges of Embodiment: Determinants of Breastfeeding for First Nations Women Rachel Eni,1 Wanda Phillips-Beck,2 and Punam Mehta1
Abstract
Background: In Canada, First Nations women are far less likely to breastfeed than other women. First Nations people have been subjected to massive health and social disparities and are at the lowest end of the scale on every measure of well-being. The purpose of this study is to understand the experiences, strengths, and challenges of breastfeeding for First Nations women. Central to the current research is the notion of an embodiment within indigenous women’s health and, more specifically, breastfeeding perspectives. Materials and Methods: Guided by an indigenous feminist standpoint, our research study evolved through honest discussions and is informed by relevant public health literature on breastfeeding. We collected quantitative data through a survey on demographics and feeding practices, and we conducted focus groups in three Canadian provinces (British Columbia, Manitoba, and Ontario) over a period of 1 year (2010) from 65 women in seven First Nation communities. Results: Three overarching themes are discussed: social factors, including perceptions of self; breastfeeding environments; and intimacy, including the contribution of fathers. The main findings are that breastfeeding is conducive to bed sharing, whereas a history of residential school attendance, physical and psychological trauma, evacuations for childbirth, and teen pregnancy are obstacles to breastfeeding. Also, fathers play a pivotal role in a woman’s decision to breastfeed. Conclusions: Findings from this study contribute to informing public health by reconsidering simplistic health promotion and public health policies and, instead, educating First Nations communities about the complexity of factors associated with multiple breastfeeding environments.
Background
B
reastfeeding has significant benefits for mothers and babies.1 As a result, the World Health Organization advocates exclusive breastfeeding for the first 6 months of life.2 The message is echoed at all levels by health authorities from local to national and international levels.3–5 Notwithstanding such encouragement, breastfeeding rates in many countries, and particularly those of exclusive and continued breastfeeding, fall short of the recommended ‘‘ideal.’’ In Canada, although 87% mothers initiate breastfeeding, far fewer (16.4%) breastfeed exclusively to 6 months.6 Within Canadian society there are huge discrepancies among populations. For example, fewer than half of First Nation mothers are initiating breastfeeding.7 Health and social disparities between First Nations and the general Canadian population are well known. The history is a sad one that includes ideals of a colonialist government and culminates in current-day environmental disputes and the 1 2
impacts of assimilationist, yet marginalizing, policies and practices. A specific example affecting maternal and infant health is the ongoing practice of evacuation of childbearing women, often leaving women separated from family and community to deliver alone in urban tertiary-care centers.8,9 This study implemented a participatory, qualitative methodology emphasizing both social–ecological and indigenous feminist standpoint perspectives to explore the following questions: Why do far fewer First Nation women initiate breastfeeding than other Canadians? What are First Nation women’s perspectives of breastfeeding and infant feeding more generally? Are social–ecological factors influential factors encouraging or discouraging the likelihood a woman will breastfeed her child? Theoretical Underpinnings
Indigenous feminist perspectives are representations of indigenous standpoints within feminism. They are essential
Department of Family Social Sciences, Faculty of Human Ecology, University of Manitoba, Winnipeg, Manitoba, Canada. Assembly of Manitoba Chiefs, Winnipeg, Manitoba, Canada.
203
204
within the discourse, as ‘‘white’’ feminism cannot go far enough to represent indigenous race and cultural issues. Moreton-Robinson10 explained that white middle-class women enjoy a racist privilege based in colonization and dispossession of indigenous nations. Circumstances disproportionately affect women depending on the social–cultural, economic, and geographic spaces with which they are identified. These circumstances affect access to resources as well as social status and cannot be ignored or removed from the subject of meaningful analysis. Subsequently, as Grande11 wrote, women (cannot) position themselves ‘‘on the same side’’ without regard for differences in power and privilege. In other words, the answer to ‘‘why women breastfeed their babies (or not)’’ lies somewhere within stories and interpretations of identities, environments, social justice, and power (re-)balance(ing). To conceive of conversations about indigenous maternal and infant health, bodies and perspectives of bodies, nourishment, and nurturing among women of different race, cultural, and socioeconomic populations, conversations would need to be rooted within a common perspective that is both inclusive and power balancing. Traditionally, First Nation women were central to community social–political activities, operating on principles of balance and consensus.12 Patriarchy is a colonial and not a traditionally indigenous construct, therefore leaving some writers to question the appropriateness of feminist theories within indigenous research at all. The existence of interrelationships between (our)selves and social and physical environments is a critical principle within indigenous thought. More broadly, social–ecological theories allow for analyses of an unfolding of health and human development within an ecological spectrum. Theories consider personal and immediate environments (microsystems) and their connections through to the most distal and ideological environments (macrosystems). They may account for historical occurrences and their manifestations through time (i.e., intergenerational impacts). Similarly to indigenous (feminist) standpoint theory, social–ecological theories are premised on the assumption that health (including our perspectives and behaviors) cannot be understood apart from factors in our physical and social environments, and the theories consider the complex interplay among the factors.13 Integrating social– ecological with traditional indigenous knowledge theories is common within health and environmental research. An emphasis on traditional knowledges first is tantamount to social justice, sovereignty, and identity priorities.14 Central to the current research is the notion of an embodiment within indigenous women’s health, and, more specifically, breastfeeding perspectives. In 2005, Adelson15 wrote of ‘‘an embodiment of inequality’’ in her article on health disparities of indigenous Canadians. Embodiment was regarded as an etching beyond the skin of realities of an unjust social world, presenting as psychosomatic impacts altering morbidity and, ultimately, mortality patterns. On inequitable political environments, Adelson wrote: A history of colonialist and paternalistic wardship, including the creation of the reserve system; forced relocation of communities to new and unfamiliar lands; the forced removal and subsequent placement of children into institutions or far away from their families and communities..15
ENI ET AL.
These political environments are absorbed onto bodies, such that Societal inequities exact a high personal toll in the form of disease, disability, violence and premature death. Thus while we may talk about Aboriginal populations in general terms, we must appreciate the individual effects of the collective burden of a history of discriminatory practices, unjust laws and economic or political disadvantage.15
Sociologically speaking, embodiment is the process by which a society’s ideals about race, gender, culture, or class create expectations for, influence, or augment our physical bodies.16 A bidirectional relationship exists between culture and biology; by reinforcing ideals we embody them, shaping physical selves, temporarily or, often, permanently. Extreme examples may be breast augmentations of Western society17 and the foot binding practices of Chinese society.18 In the current study, we studied embodiment in terms of its impact on breastfeeding and more inclusively, women’s relationships to self, body, and their babies. Societal messages imprint on women’s bodies and perceptions of bodies affecting the likelihood that they will breastfeed and the feelings they will associate with it. Within medicine, women’s bodies are conceptualized as vessels within which reproduction and birth take place. As such, alienation and separation from self and body (and breastmilk as product) are imposed. Embodiments of inequity within First Nation maternal health can be seen in chronic health discrepancies (e.g., gestational diabetes), lifestyle differences (e.g., smoking in pregnancy), and women’s decisions not to eat country foods for fear of contamination by environmental technologies.19,20 The result of the alienation and separation of the woman’s body from the rest of ecology is both a victimization of the individual and a pitting of one against the environment and social support systems within which we have been traditionally, naturally nurtured and sustained. Materials and Methods
The University of Manitoba Research Ethics Board approved the study. Community- and regional-level approvals from First Nation communities and regions were also provided, in respectful implementation of Canadian indigenous research protocol. Active participation in community programs by researchers preceded data collection. In many communities, R.E. and W.P.-B. have previously solidified long-time research and programming partnerships over the course of implementation of the maternal and infant health research programs. Four of the six researchers are indigenous women. Three are Canadian First Nation women. Two are indigenous of the global community (Middle East and India). Communications among the researchers involved understanding roles, responsibilities, and affiliations within our communities and between home and family as well as within greater societies. Sixty-five women participated in the study. Recruitment was by purposive sampling. There were from eight to 14 women in each group. All were mothers with at least one child
At the Edges of Embodiment: Determinants of Breastfeeding for First Nations Women Rachel Eni,1 Wanda Phillips-Beck,2 and Punam Mehta1
Abstract
Background: In Canada, First Nations women are far less likely to breastfeed than other women. First Nations people have been subjected to massive health and social disparities and are at the lowest end of the scale on every measure of well-being. The purpose of this study is to understand the experiences, strengths, and challenges of breastfeeding for First Nations women. Central to the current research is the notion of an embodiment within indigenous women’s health and, more specifically, breastfeeding perspectives. Materials and Methods: Guided by an indigenous feminist standpoint, our research study evolved through honest discussions and is informed by relevant public health literature on breastfeeding. We collected quantitative data through a survey on demographics and feeding practices, and we conducted focus groups in three Canadian provinces (British Columbia, Manitoba, and Ontario) over a period of 1 year (2010) from 65 women in seven First Nation communities. Results: Three overarching themes are discussed: social factors, including perceptions of self; breastfeeding environments; and intimacy, including the contribution of fathers. The main findings are that breastfeeding is conducive to bed sharing, whereas a history of residential school attendance, physical and psychological trauma, evacuations for childbirth, and teen pregnancy are obstacles to breastfeeding. Also, fathers play a pivotal role in a woman’s decision to breastfeed. Conclusions: Findings from this study contribute to informing public health by reconsidering simplistic health promotion and public health policies and, instead, educating First Nations communities about the complexity of factors associated with multiple breastfeeding environments.
Background
B
reastfeeding has significant benefits for mothers and babies.1 As a result, the World Health Organization advocates exclusive breastfeeding for the first 6 months of life.2 The message is echoed at all levels by health authorities from local to national and international levels.3–5 Notwithstanding such encouragement, breastfeeding rates in many countries, and particularly those of exclusive and continued breastfeeding, fall short of the recommended ‘‘ideal.’’ In Canada, although 87% mothers initiate breastfeeding, far fewer (16.4%) breastfeed exclusively to 6 months.6 Within Canadian society there are huge discrepancies among populations. For example, fewer than half of First Nation mothers are initiating breastfeeding.7 Health and social disparities between First Nations and the general Canadian population are well known. The history is a sad one that includes ideals of a colonialist government and culminates in current-day environmental disputes and the 1 2
impacts of assimilationist, yet marginalizing, policies and practices. A specific example affecting maternal and infant health is the ongoing practice of evacuation of childbearing women, often leaving women separated from family and community to deliver alone in urban tertiary-care centers.8,9 This study implemented a participatory, qualitative methodology emphasizing both social–ecological and indigenous feminist standpoint perspectives to explore the following questions: Why do far fewer First Nation women initiate breastfeeding than other Canadians? What are First Nation women’s perspectives of breastfeeding and infant feeding more generally? Are social–ecological factors influential factors encouraging or discouraging the likelihood a woman will breastfeed her child? Theoretical Underpinnings
Indigenous feminist perspectives are representations of indigenous standpoints within feminism. They are essential
Department of Family Social Sciences, Faculty of Human Ecology, University of Manitoba, Winnipeg, Manitoba, Canada. Assembly of Manitoba Chiefs, Winnipeg, Manitoba, Canada.
203
204
within the discourse, as ‘‘white’’ feminism cannot go far enough to represent indigenous race and cultural issues. Moreton-Robinson10 explained that white middle-class women enjoy a racist privilege based in colonization and dispossession of indigenous nations. Circumstances disproportionately affect women depending on the social–cultural, economic, and geographic spaces with which they are identified. These circumstances affect access to resources as well as social status and cannot be ignored or removed from the subject of meaningful analysis. Subsequently, as Grande11 wrote, women (cannot) position themselves ‘‘on the same side’’ without regard for differences in power and privilege. In other words, the answer to ‘‘why women breastfeed their babies (or not)’’ lies somewhere within stories and interpretations of identities, environments, social justice, and power (re-)balance(ing). To conceive of conversations about indigenous maternal and infant health, bodies and perspectives of bodies, nourishment, and nurturing among women of different race, cultural, and socioeconomic populations, conversations would need to be rooted within a common perspective that is both inclusive and power balancing. Traditionally, First Nation women were central to community social–political activities, operating on principles of balance and consensus.12 Patriarchy is a colonial and not a traditionally indigenous construct, therefore leaving some writers to question the appropriateness of feminist theories within indigenous research at all. The existence of interrelationships between (our)selves and social and physical environments is a critical principle within indigenous thought. More broadly, social–ecological theories allow for analyses of an unfolding of health and human development within an ecological spectrum. Theories consider personal and immediate environments (microsystems) and their connections through to the most distal and ideological environments (macrosystems). They may account for historical occurrences and their manifestations through time (i.e., intergenerational impacts). Similarly to indigenous (feminist) standpoint theory, social–ecological theories are premised on the assumption that health (including our perspectives and behaviors) cannot be understood apart from factors in our physical and social environments, and the theories consider the complex interplay among the factors.13 Integrating social– ecological with traditional indigenous knowledge theories is common within health and environmental research. An emphasis on traditional knowledges first is tantamount to social justice, sovereignty, and identity priorities.14 Central to the current research is the notion of an embodiment within indigenous women’s health, and, more specifically, breastfeeding perspectives. In 2005, Adelson15 wrote of ‘‘an embodiment of inequality’’ in her article on health disparities of indigenous Canadians. Embodiment was regarded as an etching beyond the skin of realities of an unjust social world, presenting as psychosomatic impacts altering morbidity and, ultimately, mortality patterns. On inequitable political environments, Adelson wrote: A history of colonialist and paternalistic wardship, including the creation of the reserve system; forced relocation of communities to new and unfamiliar lands; the forced removal and subsequent placement of children into institutions or far away from their families and communities..15
ENI ET AL.
These political environments are absorbed onto bodies, such that Societal inequities exact a high personal toll in the form of disease, disability, violence and premature death. Thus while we may talk about Aboriginal populations in general terms, we must appreciate the individual effects of the collective burden of a history of discriminatory practices, unjust laws and economic or political disadvantage.15
Sociologically speaking, embodiment is the process by which a society’s ideals about race, gender, culture, or class create expectations for, influence, or augment our physical bodies.16 A bidirectional relationship exists between culture and biology; by reinforcing ideals we embody them, shaping physical selves, temporarily or, often, permanently. Extreme examples may be breast augmentations of Western society17 and the foot binding practices of Chinese society.18 In the current study, we studied embodiment in terms of its impact on breastfeeding and more inclusively, women’s relationships to self, body, and their babies. Societal messages imprint on women’s bodies and perceptions of bodies affecting the likelihood that they will breastfeed and the feelings they will associate with it. Within medicine, women’s bodies are conceptualized as vessels within which reproduction and birth take place. As such, alienation and separation from self and body (and breastmilk as product) are imposed. Embodiments of inequity within First Nation maternal health can be seen in chronic health discrepancies (e.g., gestational diabetes), lifestyle differences (e.g., smoking in pregnancy), and women’s decisions not to eat country foods for fear of contamination by environmental technologies.19,20 The result of the alienation and separation of the woman’s body from the rest of ecology is both a victimization of the individual and a pitting of one against the environment and social support systems within which we have been traditionally, naturally nurtured and sustained. Materials and Methods
The University of Manitoba Research Ethics Board approved the study. Community- and regional-level approvals from First Nation communities and regions were also provided, in respectful implementation of Canadian indigenous research protocol. Active participation in community programs by researchers preceded data collection. In many communities, R.E. and W.P.-B. have previously solidified long-time research and programming partnerships over the course of implementation of the maternal and infant health research programs. Four of the six researchers are indigenous women. Three are Canadian First Nation women. Two are indigenous of the global community (Middle East and India). Communications among the researchers involved understanding roles, responsibilities, and affiliations within our communities and between home and family as well as within greater societies. Sixty-five women participated in the study. Recruitment was by purposive sampling. There were from eight to 14 women in each group. All were mothers with at least one child
