Midw,/e~ (1992)8, (~) Longman Group103-112 UK Ltd 1992
Midwifery
Attitudes of Vietnamese women to baby feeding practices before and after immigration to Sydney, Australia Joh Chin Rossiter
T h e purpose o f this study was to explore Vietnamese women's attitudes, behaviour and beliefs towards baby f e e d i n g practices before a n d after immigration to Sydney. Findings f r o m 70 questionnaires and 20 in-depth face-to-face interviews with ethnic Vietnamese w o m e n indicated that Vietnamese women's preference towards baby feeding practices was shaped by their health beliefs, which in turn were influenced by the social, cultural and economic e n v i r o n m e n t of the host country. C h a n g i n g to bottle feeding was an adaptation process, a bridge between the old and the new environments. R e c o m m e n d a t i o n s have been m a d e regarding ways of promoting breast feeding a m o n g immigrant women.
INTRODUCTION Over the last decade, there has been an influx of Indo-Chinese people, predominantly Vietnamese, into Australia. According to the Australian Bureau of Immigration Research (1989) Indo-Chinese people account for 48% of new settlers to Australia under the Special Humanitarian Program. Among these new settlers, 81% are Vietnamese. A large number of them have settled in Sydney's western and southwestern suburbs (Migrant Services Unit, 1986). While the morale of these settlers is generally high, many suffer from social and health problems due to cultural, racial and language differJob Chin Rossiter BSc, DNE, SRN, SCM, Lecturer, Faculty of Health Studies, University of Western Sydney, Nepean, PO Box 10, Kingswood NSW 2747, Australia. Manuscript accepted 13 May 7992 Requests for offprints to JCR
ences. One of the problems associated with maternal-child health is the abandonment of their traditional baby-feeding practices (Manderson & Mathews, 1981). Traditionally most Vietnamese women breast feed their children for a prolonged period (Manderson & Mathews, 1981). Recently, with the increasing recognition and awareness of its multiple benefits, breast feeding has escalated in western countries (Hitchcock & Coy, 1988). Yet, reports from literature and a pilot study conducted by this author indicate that there is a significant reduction in breast feeding among Vietnamese women after immigration to western countries (Mathews & Manderson, 1980; Henderson & Brown, 1987; Fishman et al, 1988; Romero-Gwynn, 1989; Rossiter et al, 1990). Mathews and Manderson (1980) reported that out of the 40 respondents in their study 75% breast fed in Vietnam, the average length of breast feeding being nine months. The rate of 103
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breast feeding declined to 40%, with an average length of 3.3 months, after settlement in Sydney. Changes in the baby feeding practices tollowing migration appeared to be motivated by economic rather than cultural factors. This was because the women, in an attempt to establish themselves and their families in the new country, entered the work force as soon as possible after confinement (Manderson & Mathews, 198 I). Henderson and Brown (1987) noted that 85% of subjects breast fed in Vietnam but only 15% continued to do so in the USA. T h e study concluded that 'Vietnamese women's infant feeding behaviour appears to be influenced mainly by perceived custom, together with the desire for freedom and convenience'. Most Vietnamese women in the study associated breast feeding with physical discomfort, embarrassment, restriction o f their freedom, neglecting other family members and anxiety over sufficient milk supply. T h e y believed that the Western way of baby feeding was by bottle and that artificial milk was just as beneficial as breast milk. Above all, they saw little difference in the health of breast-fed and artificially-fed babies. Romero-Gwynn (1989) obtained a similar finding with Indo-Chinese immigrants in Northern California. While 97% of the women breast fed their last baby born in Indo China, only 22% breast fed their children who had been born in the USA. For those who did breast feed, the duration of breast feeding decreased from an average of 20.4 months in Indo China to 8.7 months in the USA. Reasons for the decline in breast feeding among the Vietnamese immigrants in the sample were the provision of artificial milk samples at the time of discharge from hospital, the women's limited knowledge and awareness of the advantages o f breast feeding for the babies and the mothers, and the conflict between their traditional practices and those of the host culture. In contrast with the above findings Reynolds et al (1988) indicated that there was no decrease in the rate of breast feeding among Vietnamese immigrants to Perth, Western Australia. They further suggested that the rate of breast feeding among these women was comparable with that of
Australian women living in the same city, 81% versus 82% respectively. Leininger (1988) explained that an individual's thinking, decisions and actions are guided by culture. Culture is the 'learned, shared and transmitted values, beliefs, norms and lifeway practices of a particular group of people in the society or environment in which they live (Leininger, 1988). T h e society or environment includes physical, ecological, social, emotional and cultural dimensions which interact to give rise to live experience. Upon immigration to a new country an individual's beliefs, values and life practices undergo modification and adaptation due to the environmental changes. This conceptual framework could be applied to the Vietnamese immigrants and their baby feeding practices. In order to reduce stress, and to prevent conflict and rejection from the host country, they learned to comply and adapt quickly to their new environment. T h e decision on baby-feeding practices was hence a process of adaptation (Leininger, 1987). Previous studies have demonstrated that physical, cultural and economic influences have affected the decline in the incidence of breast feeding among Vietnamese women following immigration to western countries (Mathews & Manderson, 1980; Henderson & Brown, 1987; Romero-Gwynn, 1989). However, there has been little study of how a new environment might affect Vietnamese women's decisions about baby-feeding practices. T h e purpose of this study was to discover Vietnamese women's attitudes towards baby feeding practices and to further explore the demographic, social, cultural and economic factors which might contribute to their abandonment of their traditional breast-feeding practices following immigration to Sydney. The assumptions upon which this study was based were that: 1) the demographic, social, cultural and economic factors were the predominant factors that influence the attitudes of Vietnamese women towards baby-feeding practices; 2) the process o f adaptation following immigration affected the Vietnamese women's decision concerning baby-feeding practices.
M1DWIFFRY
METHODS Since there was no existing tool available, a questionnaire and semi-structured, open-ended questions for interview were developed by the investigator. Both methods of data collection were used to increase confidence and validity in the findings. T h e items in the questionnaire and the open-ended questions in the interview focused on significant issues arising from the literature review and the author's previous pilot study to elicit: l) the participants' reasons for the choice of feeding method in Vietnam and in Australia; 2) the demographic, nutritional, cultural, socio-economic, body image and social support factors which might influence the decision of the baby-feeding method. Demographic factors included the women's age, place of birth, language(s) spoken, length of residence in Australia, marital status and n u m b e r of children in the family. Nutritional factors were assessed by the woman's knowledge and perception of breast milk and artificial milk. Cultural factors were raised by questions concerning maternal dietary preferences and restrictions related to breast feeding, other post natal behavioural practices and the perception of customary baby feeding practices in Vietnam and in Australia. Socio-economic factors elicited were income, education, and the e m p l o y m e n t status of the woman and her husband. Body image factors included her perception of lactation with her health, size of breast, attractiveness, embarrassment, fashion, work and social freedom. Social support and social influences were assessed by size and composition of the family household and assistance available. A Likert scale of five categories was used in the questions of nutritional, cultural, body image and social support factors to determine the opinion or attitudes of participants. In the interview the participants were asked 10 open-ended questions designed to probe their knowledge and attitudes concerning baby
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feeding practices before and after immigration to Australia. Content validity of the questionnaire and the interview questions were assessed by two independent health scientists with expertise in the development o f questionnaires and maternal-infant nursing. Both the questionnaire and the interview questions were then translated into the Vietnamese language by a bi-lingual translator. T o ensure the accuracy o f the translation they were p r o o f read by independent professional translators. A pilot study, where 20 women received questionnaires and seven were interviewed, was conducted in early 1990 to determine the adequacy of the instrumentation.
Sample A sample of convenience consisting of 70 ethnic Vietnamese women whose ages ranged from 20 to 42 years (mean = 34 years) was recruited. All of them were born in Vietnam and married. T h e length of residence in Australia ranged from two to seven years (mean = 4.5 years). In order to compare baby-feeding practices, the women had to have had at least one child born in Vietnam and one child b o r n in Australia. Both babies must have been b o r n normally and at full term to eliminate poor baby physical condition as a basis for decisions regarding feeding method. T h e n u m b e r of children the women had ranged f r o m two to five (mean = 2.6). O f the 70 women, 43 were recruited through word of mouth or by knocking on doors in the Vietnamese area of residence around western and south western Sydney. Twenty seven were recruited from two Early Childhood Centres and a hospital maternity unit. T h e women were categorised into two major groups: 1) the breast-feeding g r o u p who breast fed both in Vietnam and in Australia (n = 47) and; 2) the artificial-feeding g r o u p who breast fed in Vietnam but artificially fed in Australia (n = 23). Each participant was provided with a questionnaire to complete whilst in the maternity ward, waiting in the Early Childhood Clinic for an a p p o i n t m e n t or in the participant's own
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home. Following the completion of the questionnaire interviews were conducted with 20 women who volunteered to participate. A research assistant who was fluent in both Vietnamese and English assisted the participants with the questionnaires and conducted interviews. All the interviews were conducted in the privacy o f the woman's home. Interview sessions averaged one and a half hours.
Data Analysis T h e quantitative data obtained from the questionnaire were analysed statistically, using frequency distributions, means and differences in proportions. T h e content o f qualitative data from large tracts o f verbatim interviews were tabled, interpreted and summarised. Selected aspects of the qualitative data are presented in this paper.
FINDINGS Baby feeding before and after immigration In Vietnam all of the 70 women had breast fed their children for a prolonged period. T h e length o f breast feeding ranged from 1 to 30 months (mean = 11 months). After immigration to Australia there was a sharp decline in breast feeding. Only 18 (26%) of these women breast fed exclusively, 29 (41%) breast fed partially and 23 (33%) artificially fed their Australian born baby. For those women who breast fed their Australian born baby, the duration o f breast feeding ranged from 1 to 18 months (mean = 6).
Socio-economic factors and their relationship to breast feeding Findings from the demographic and socio-economic data (Table 1) showed that 60% o f breastfeeding women were employed compared with 65% of those who artificially fed. However, more breast-feeding women (43%) than artificially feeding women (30%) h a d achieved an income in the range o f $ 2 1 0 0 0 to $30900 per annum. A higher percentage of husbands (83%) in the breast-feeding groups were employed compared with the husbands of the women in the artificially-feeding group (78%). Similarly, the husbands of the breast-feeding women (70%) earned a higher income than those who were artificially feeding (52%). In both groups of women the majority attended or completed their secondary education in Vietnam. Only 40% of the breast-feeding women initiated or attained their tertiary education in Vietnam but none of the artificially-feeding women achieved the same tertiary education. In Vietnam, the women lived in extended families and were guided by their mother or mother-in-law. Upon immigration to Sydney families decreased in size and changed in form. Some of the breast-feeding women (38%) had parents and/or parents-in-law living with them and 40% relied on friends for assistance. However, only 13% of the artificially feeding women had the same extended family life style and 57% relied on the assistance of friends (Figure 1). These findings suggested that women who completed a higher level of education, earned a higher income and who had a greater level of
Table 1 Comparison of the sociodemographic characteristics of the two groups of Vietnamese women in Sydney Variables Employment Income $20-$30,000/a Husband's employment Husband's income $20-30,000/a Women's tertiary education Extended family Dependent on friends
Breast feeding group (n = 47) N 28 20 39 33 19 18 19
% 60 43 83 70 40 38 40
Artificial feeding group (n = 23) N 15 7 18 12 3 13
% 64 30 78 52 13 57
Z Value
p
0.455 0.979 0.476 1.479 3.572 1.520 1.269
ns ns ns
ns p < 0.05 ns ns
M|DWIFERY
• Women from breast feeding group [] Women from artificial feeding group
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Fig. 1 Comparison of the sociodemographic data between the w o m e n in the breast feeding group and the
artificial feeding group.
assistance in the home were more likely to breast feed their baby in Australia. T h e husbands of these women were also educated to a higher level and had higher incomes than their wives. During the postnatal period, they, in turn, were looked after and guided by their mothers and mothersin-law. They were served with traditional postnatal diets to restore their health after childbirth and to enhance lactation. Upon immigration to Sydney, families decreased in size and changed in form. The women have no mother at hand from whom to seek advice nor to ask for help. They were exposed to a new and totally democratic society, the decision of baby-feeding methods was left to them and their husband. Some of the breast-feeding group (38%) had parents, parents-in-law, brothers and sisters or aunts and uncles living with them and 40% of these women relied on friends for assistance. However, only 13% of women in the artificially-
feeding group had the same extended family life style and 57% relied on the assistance of friends (Figure 1).
Factors w h i c h m a y influence baby feeding practices The cultural factors in the form of traditional customs appeared to be an important determinant of baby-feeding method when compared between the breast-feeding and artificially-feeding women. T h e majority of women in both groups (81% vs 83%) agreed that the availability of traditional foods in Vietnam was important to increase lactation (Table 2). Although the right choice of traditional foods was also available in Sydney there was a statistically significant difference in the proportion of women in the two groups who were given the foods in the
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postnatal period (83% vs 65%, z = 1.68, p < 0.05) (Table 3). T h e women found that without assistance at h o m e it was inconvenient to prepare these foods for themselves after childbirth, hence they opted for the alternative method of artificial feeding. In Vietnam, these women reported that they were able to breast feed because they were looked after (85% vs 87%) and assisted with household tasks by relatives (77% vs 70%). Since immigration to Sydney, their family structure had reduced to nuclear form; most women (45% vs 35%) were not being looked after by parents or relatives after their childbirth in Australia and they no longer received help with household chores (53% vs 35%).
T h e knowledge o f the nutritional value and benefits of breast feeding were examined. In Vietnam the majority o f both groups (94% vs 100%) agreed that breast milk had the right proportion o f nutrients that babies require (Table 3). Breast milk contained immunoglobulin to protect babies f r o m sickness (96% vs 87%). Breast feeding was natural (96% vs 96%), convenient (79% vs 83%), and hygienic (94% vs 92%). Nevertheless, the idea of breast feeding being convenient changed upon immigration to Australia (57% vs 35%) (Table 3). H a l f (51%) of the breast feeders and 65% of the artificial feeders believed that artificial milk was more nutritive and superior to breast milk. Some women (34% vs 48%) believed that artificially-
Table 2 Comparison of variables contributing to the decision of infant feeding practices in Vietnam between the women in breast-feeding group and artificial-feeding group
Variables
In Vietnam Breast feeding Artificial feeding group (n = 47) group (n = 23)
Z Value
p
Availability of traditional food Being looked after postnatally Assisted with household tasks Breast milk nutritious Breast milk protects infants from sickness Breast milk free of charge Breast milk natural
N 38 40 36 44 45 20 45
% 81 85 77 94 96 42 96
N 19 20 16 23 20 15 22
% 83 87 70 100 87 65 96
0.182 0.22 0.638 1.22 1.343 1.784 0.0194
ns ns ns
Breast feeding convenient Breast feeding hygienic Breast feeding facilitates attachment
37 44 41
79 94 87
19 21 22
83 91 96
0.383 0.366 1.10
ns ns p < 0.05
ns ns ns ns
Table 3 Comparison of variables contributing to the decision of infant feeding practices in Australia between the women in breast feeding group and artifical feeding group In Australia Artificial feeding group (n = 47) group (n = 23)
Breast feeding
Variables Availability of traditional food Being looked after postnatally Assisted with household tasks Breast feeding convenient Formula milk more nutritious Formula fed infant healthier Formula milk accessible Formula feeding not providing more freedom Breast feeding not embarrassing Breast feeding not old fashion Formula fed due to work
N 39 21 25 27 24 16 26 37 37 42 34
% 83 45 53 54 51 34 55 79 79 89 72
N 15 8 8 8 15 11 11 15 13 14 15
% 65 35 35 35 65 48 48 65 56 61 65
Z Value
p
1.68 0.784 1.44 1.31 1.123 1.114 0.984 1.21 1.932 2.79 0.6089
p < 0.05 ns ns ns
ns ns ns ns p < 0.05 p < 0.01 ns
MIr)WWERV 109 fed babies were healthier and fatter than breastfed babies. The women (55% vs 48%) also reported that the easy accessibility and relative cost of artificial milk in Australia was a factor influencing their decision to bottle feed. The notion of breast milk being free was significantly different between the two groups of women (Table 2). Only 42% of women in the breast-feeding group thought that breast milk was 'free' compared with 65% o f those in the artificial-feeding group (z = 1.784, p < 0.05). These latter women considered that the quality of a mother's milk could only be enriched by consuming a special diet which was costly. This negated the idea o f 'free' breast feeding to the majority of those women in the breast-feeding group. Factors relating to body image and attachment were also explored. Most women from both groups (87% vs 96%) agreed that breast feeding facilitated strong maternal-baby attachment. These women said they felt closer to their breast-fed babies. However, they also reported that artificial feeding did not lessen the dependency and demands the babies had on them. Similarly they (79% vs 65%) did not consider artificial feeding provided them with more freedom and time for other members of the family and housework (Table 3). Although most of these women in Australia agreed that breast feeding was not embarrassing (79% vs 56%) the difference between the two groups was statistically significant (z = 1.932, p < 0.05) (Table 3). The women in the artificiallyfeeding group considered that their breasts were too small to produce sufficient milk for their baby. They also perceived breast feeding as being unattractive and having an adverse effect on their health and figure. T h e r e was also a statistically significant difference between the two groups in the proportion of women who saw breast feeding as an old fashioned idea (z = 2.79, p < 0.01) (Table 3). Most of the breast-feeding women (89%) but only 61% of the artificiallyfeeding women agreed that breast feeding was not an old fashioned idea. Another reason for both groups of women (72% vs 65%) to select artificial feeding was that they needed to return to the workforce after
confinement. This need was economically motivated. In summary, Vietnamese women were more likely to breast feed after immigration to Australia if they had achieved a higher level of education, were provided with the correct traditional foods postnatally, did not think breast feeding was old fashioned and were not embarrased by breast feeding.
Qualitative data Qualitative analysis of the 20 in-depth interviews supported the quantitative findings. In Vietnam, the majority of women breast fed because it was the traditional thing to do. As most respondents explained, 'You see your mother breast feeding, and now its your t u r n . . , it just continued one generation after another'. Colostrum was believed to be 'stale' milk and should be discarded before the baby was put to the breast on the third postnatal day. One woman said ' . . . my mum taught us to use dates (the fruit) and rub it around the nipple to get rid of the old milk'. Traditionally, the Vietnamese believed that the health of postnatal women was weak and vulnerable. In order to regain their health, the women were required to observe postnatal rituals and dietary precautions. After childbirth the women were confined to bed for at least 30 days to avoid future health problems and to nurse their baby. Two respondents stated ' . . . my mum put me lying on the charcoal bed . . . it helps your womb contract back to normal...' ' . . . we did not have any shower straight away after c h i l d b i r t h . . , some may go as far as one month with having one shower o n l y . . . ' Dietary restriction was considered important to prevent maternal-baby illnesses and to establish lactation. A lactating woman should consume a specific high protein diet with a minimal
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etable intake to encourage milk flow and to balance both her and her baby's health. Most women interviewed explained, ' . . . definitely no sour tood, raw stuff like fruits and salads and coconut. They are very bad . . . . ' and, ' . . . my mum stewed pigs' trotters in pepper and lotus seeds or nuts for me to help my milk flOW
. . .'
It was the norm of the society that after marriage women did not return to work. Their duty was to remain at home to perform household work and to look after their children and family. During the postnatal period women were to concentrate on nursing their baby. They were, in turn, looked after by members o f their extended family. Some women reported 'I could breast feed my children because I did not have to go to work after m a r r i a g e . . . ' In Australia, these women experienced a complete change from their traditional customs in postnatal care. Babies were delivered in hospitals instead o f traditionally at home. In hospital, the women were required to get up for a shower soon after birth and to initiate breast feeding following delivery. For example, they were advised ' . . . to eat salad and orange j u i c e . . . ' , ' . . and to get out of bed and have 3 showers a day',
and ' . . to breast feed their baby as soon as s/he was born...'. Most of those interviewed had to return to work in order to assist in their family finance. Some women explained, 'It was convenient for me to bottle feed because I had to go back to w o r k . . . ' . For those who continued to breast feed in Australia it was reported 'I breast fed because I had unemployment benefit here and could stay at home l o n g e r . . . ' . With such conflicting differences between the old and new cultures, the Vietnamese women learned to adapt quickly to
the perceived ' n o r m ' o f their host country. They believed ' . . most Australian women bottle feed their babies because they have to go back to work •..'. Moreover, ' . . . powdered milk here has so much nutrition, not like those in V i e t n a m . . . I noticed my baby is a lot bigger to()...'•
DISCUSSION In this study a considerable decline in the rate and duration o f breast feeding has been demonstrated a m o n g Vietnamese women after immigration to Australia• T h e women who changed to artificial feeding in Australia were found to be from a lower socio-economic background, with a lower level of" education and a smaller income than those who breast fed. They had little support or guidance provided by family members to assist them with the traditional postpartum rituals in caring for themselves and their baby. These findings concur with the findings of Mathews & Manderson (1980), Henderson & Brown (1987) and Romero-Gwynn (1989). The findings o f this study differ from those o f Reynold et al (1988) in which no decline in the rate and duration o f breast feeding was found among the Vietnamese women in their sample. This may be due to sample differences. The women in their study were selected from a migrant hostel or shared accommodation with other Vietnamese families. Although the majority of those in Reynold et al's (1988) study had lived in Perth for 8 to 16 months, they remained in a close community network, maintaining traditional customs and baby-feeding practices. Thus, it is possible that the large majority o f those Vietnamese women continued to breast feed because of the strong community link; and they had not been exposed to the freedom and choice of artificial milk available in the host country. Findings from both qualitative and quantitative data in this study indicate that Vietnamese women's baby-feeding practices are shaped by their health beliefs: the beliefs about maternal health, about the baby's health and the family's health. These findings also suggest that both
MIDWIFERY 1 11 their baby-feeding practices and health beliefs are influenced by the social, cultural and economic factors o f their environment. T h e Vietnamese women believed that maternal health is weakened by childbirth. T o restore health, it is necessary for a w o m a n to follow the traditional postnatal rituals and dietary restrictions. A delicately balanced maternal diet is believed to enhance maternal and baby health and to encourage lactation. Vietnamese women consider babies are healthy if they are fat and putting on weight. Although it is agreed that breast milk is more nutritious than artificial milk it is said that the quality of breast milk is d e p e n d e n t upon the health of the lactating m o t h e r (Fishman et al. 1988). I f a woman is weak, suffering from any illness, taking medications or has had an operation, her milk is thought to be inferior and may transmit maternal diseases or health problems to her baby. In such instances the baby may often be artificially fed despite beliefs that artificial milk in Vietnam is poor in quality, expensive and not readily available. In Vietnam family health is based on the status, position and roles o f individuals in an extended family. T h e role o f a husband is to provide for the financial needs o f the family. A woman is expected to be a housewife and to care for her children and her elderly parents. She is not required to seek e m p l o y m e n t or to pursue her career once she is married. H e r mother or mother-in-law are usually involved in all the health care decisions of the family including the decision concerning baby-feeding practices (Rocereto, 1981). During the postnatal period, a woman is relieved of all household chores, including the care of her baby. H e r only responsibility is to breast feed her newborn baby. She is looked after and guided by her m o t h e r or mother-in-law and served with a traditional postnatal diet to restore her health after childbirth and to enhance lactation. Following immigration to Syndey there was a dramatic change in the social, cultural and economic environment for the women in o u r sample. Most of the women in the study became separated from their extended family. T h e y were therefore b u r d e n d e d with the responsibili-
ties of carrying out the day-to-day household tasks and had to make decisions, including the decision on baby feeding, for themselves without any guidance f r o m other family members. T h e problems were c o m p o u n d e d after childbirth in that they found themselves unable to follow the traditional postnatal ritual and dietary precautions without the assistance of their m o t h e r and/or mother-in-law. In order to establish a strong economic base for their family, most of the women were required to return to work soon after childbirth. Moreover the Vietnamese women believed that most Australian women bottle feed their babies and that artificial milk in Australia is superior in quality to that in Vietnam and to breast milk. In order not to further jeopardise their own health and their baby's health in future they abandoned their traditional baby feeding practices. Findings f r o m this study show some of the health beliefs of Vietnamese immigrants. T h e y also demonstrate how the social cultural and economic environment in Vietnam facilitate breast feeding. U p o n immigration, the traditional baby-feeding practices undergo modification due to the influence of the new environment. Artificial feeding is a 'forced choice' (Leininger, 1987) to maintain maternal and baby health while trying to accommodate the culture of the host country. Clearly, Vietnamese women experience social, cultural and economic problems of significant magnitude following immigration to Australia. These problems not only disrupt their lives but also motivate them to modify their cultural values. In order to be accepted and to survive in a new country Vietnamese immigrants, being pragmatists, are p r e p a r e d to adapt quickly to the perceived host cultures and practices (Leininger, 1987). Changing to artificial feeding is an adaptation process to the new environment, they believe, without too much compromise to their own health and traditional customs. Research has demonstrated the 'unique properties of h u m a n milk and the psycho-phsysiological significance of breast feeding' (Jelliffe & Jellife, 1978). Although the rate of breast feeding in Western countries has increased there is a considerable decline in the incidence and
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d u r a t i o n o f b r e a s t f e e d i n g a m o n g i m m i g r a n t s to W e s t e r n countries. I n line with t h e r e c o m m e n d a t i o n o f W H O (1981) t h e m a j o r goal in m a t e r n a l - c h i l d h e a l t h care is to e n c o u r a g e a n d s u p p o r t b r e a s t feeding. I n o r d e r to p r o m o t e a n d encourage breast feeding among immigrant women, it is strongly a d v i s e d t h a t t h e following r e c o m m e n d a t i o n s s h o u l d be c o n s i d e r e d a n d adopted: 1) It is crucial for midwives, h e a l t h c a r e workers, r e s e a r c h e r s a n d a c a d e m i c s to u n d e r s t a n d the social, c u l t u r a l a n d economic c o n t e x t o f the baby f e e d i n g practices o f i m m i g r a n t s . As stated by L e i n i n g e r (1984) a culturally sensitive a n d knowl e d g e a b l e m i d w i f e will receive m o r e positive r e s p o n s e f r o m the e t h n i c clients t h a n o n e who is not; 2) It is necessary to d e v e l o p e d u c a t i o n a l p r o g r a m m e s which a r e u n i q u e f o r a p a r t i c u l a r ethnic g r o u p . A u d i o - v i s u a l materials, videotape education programmes should be socially, c u l t u r a l l y a n d l a n g u a g e specific, a i m i n g to dismiss the m i s c o n c e p t i o n s conc e r n i n g b a b y - f e e d i n g practices in W e s t e r n countries. I n d i v i d u a l c o u n s e l l i n g a n d small g r o u p discussion p r o v i d e d by e t h n i c h e a l t h w o r k e r s a r e m o s t valuable. T h e use o f these e d u c a t i o n p r o g r a m m e s s h o u l d be m a d e available to schools a n d e t h n i c organisations in the c o m m u n i t y as well as in hospitals; 3) C o n t i n u o u s s u p p o r t a n d e n c o u r a g e m e n t o f b r e a s t f e e d i n g s h o u l d be given to i m m i grant women throughout their pregnancy, labour and puerperium; 4) B r e a s t - f e e d i n g c o n s u l t a n t services p r o v i d e d by midwives a n d h e a l t h c a r e w o r k e r s f r o m the s a m e ethnic g r o u p s in Early C h i l d h o o d C e n t r e s w o u l d be essential. 5) C u l t u r a l studies s h o u l d b e i m p l e m e n t e d in all m i d w i f e r y a n d n u r s i n g c u r r i c u l a in o r d e r to i n c r e a s e a w a r e n e s s o f cultural d i f f e r e n c e s , h e n c e to i m p r o v e t h e h e a l t h o f immigrants; Finally, it w o u l d be an i n n o v a t i v e c o n c e p t for La L e c h e L e a g u e I n t e r n a t i o n a l o r a n y association
f o r b r e a s t - f e e d i n g w o m e n to c o n s i d e r r e c r u i t i n g ethnic m e m b e r s to assist w o m e n f r o m various ethnic g r o u p s with b r e a s t feeding.
References Australian Bureau of Immigration Research 1988/89 Country of Birth and Settler Arrivals, Department of Immigration. Local Government and Ethnic Affairs, Canberra Fishman C, Evans R, Jenks E 1989 Warm bodies, cool milk: conflicts in postpartum food choice for Indo Chinese woman in California. Social Science and Medicine 26 (11): 1125-1132 Henderson A M, Brown J S 1987 Infant feeding practices of Vietnamese immigrants to the Northwest United States. Scholarly Inquiry for Nursing Practice 1 (2): 153-169 Hitchcock N E, CoyJ F 1988 Infant feeding practices in Western Australia and Tasmania: a joint survey 1984-1985. The Medical Journal of Australia 148: 114-117 Jelliffe D B, Jelliffe E F P 1978 Human milk in the modern world. Oxford University Press, Oxford Leininger M M 1984 Transcultural Nursing: an essential knowledge and practice field for today. The Canadian Nurse, Dec. 41-45 Leininger M M 1987 Response to 'Infant Feeding Practices of Vietnamese Immigrants to the Northwest United States'. Scholarly Inquiry for Nursing Practice 1 (2): 171-174 Leininger M M 1988 Leininger's Theory of Nursing: Cultural Care Diversity and University. Nursing Science Quarterly 1:152-160 Manderson L, Mathews M 1981 Vietnamese attitudes towards maternal and infant health. The Medical Journal of Australia 1: 69-72 Mathews M, Manderson L 1980 Infant feeding practices and lactation diets amongst Vietnamese immigrants. Australian PaediatricsJournal 16:263-266 Migrant Services Unit 1986 Communicating with Migrant Clients: A Training Kit and Resource Guide. Department of Social Security, Sydney Reynolds B, Hitchcock N C, Conveney J 1988 A longitudinal study of Vietnamese children born in Australia: Infant feeding, growth in infancy and after five years. Nutritional Research 8:593-603 Rocereto L 1981 Selected health beliefs of Vietnamese refugees. Journal of School Health Jan: 63-64 Romero-Gwynn E 1989 Breast feeding pattern among Indo Chinese immigrants in Northern California. American Journal of Disease Children 143:804-808 Rossiter J C, Ledwidge H, Coulon Let al 1990 The relevance of changes in Indo Chinese women's attitudes to breast feeding following immigration: a pilot study. Proceedings of Symposium: Reaching for Relevance. The New South Wales Nurses Interest Group World Health Organization 1981 Guidelines on Implementation of WHO International Code of marketing of Breast Milk Substitutes. WHO, Geneva.
Midwifery
Attitudes of Vietnamese women to baby feeding practices before and after immigration to Sydney, Australia Joh Chin Rossiter
T h e purpose o f this study was to explore Vietnamese women's attitudes, behaviour and beliefs towards baby f e e d i n g practices before a n d after immigration to Sydney. Findings f r o m 70 questionnaires and 20 in-depth face-to-face interviews with ethnic Vietnamese w o m e n indicated that Vietnamese women's preference towards baby feeding practices was shaped by their health beliefs, which in turn were influenced by the social, cultural and economic e n v i r o n m e n t of the host country. C h a n g i n g to bottle feeding was an adaptation process, a bridge between the old and the new environments. R e c o m m e n d a t i o n s have been m a d e regarding ways of promoting breast feeding a m o n g immigrant women.
INTRODUCTION Over the last decade, there has been an influx of Indo-Chinese people, predominantly Vietnamese, into Australia. According to the Australian Bureau of Immigration Research (1989) Indo-Chinese people account for 48% of new settlers to Australia under the Special Humanitarian Program. Among these new settlers, 81% are Vietnamese. A large number of them have settled in Sydney's western and southwestern suburbs (Migrant Services Unit, 1986). While the morale of these settlers is generally high, many suffer from social and health problems due to cultural, racial and language differJob Chin Rossiter BSc, DNE, SRN, SCM, Lecturer, Faculty of Health Studies, University of Western Sydney, Nepean, PO Box 10, Kingswood NSW 2747, Australia. Manuscript accepted 13 May 7992 Requests for offprints to JCR
ences. One of the problems associated with maternal-child health is the abandonment of their traditional baby-feeding practices (Manderson & Mathews, 1981). Traditionally most Vietnamese women breast feed their children for a prolonged period (Manderson & Mathews, 1981). Recently, with the increasing recognition and awareness of its multiple benefits, breast feeding has escalated in western countries (Hitchcock & Coy, 1988). Yet, reports from literature and a pilot study conducted by this author indicate that there is a significant reduction in breast feeding among Vietnamese women after immigration to western countries (Mathews & Manderson, 1980; Henderson & Brown, 1987; Fishman et al, 1988; Romero-Gwynn, 1989; Rossiter et al, 1990). Mathews and Manderson (1980) reported that out of the 40 respondents in their study 75% breast fed in Vietnam, the average length of breast feeding being nine months. The rate of 103
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breast feeding declined to 40%, with an average length of 3.3 months, after settlement in Sydney. Changes in the baby feeding practices tollowing migration appeared to be motivated by economic rather than cultural factors. This was because the women, in an attempt to establish themselves and their families in the new country, entered the work force as soon as possible after confinement (Manderson & Mathews, 198 I). Henderson and Brown (1987) noted that 85% of subjects breast fed in Vietnam but only 15% continued to do so in the USA. T h e study concluded that 'Vietnamese women's infant feeding behaviour appears to be influenced mainly by perceived custom, together with the desire for freedom and convenience'. Most Vietnamese women in the study associated breast feeding with physical discomfort, embarrassment, restriction o f their freedom, neglecting other family members and anxiety over sufficient milk supply. T h e y believed that the Western way of baby feeding was by bottle and that artificial milk was just as beneficial as breast milk. Above all, they saw little difference in the health of breast-fed and artificially-fed babies. Romero-Gwynn (1989) obtained a similar finding with Indo-Chinese immigrants in Northern California. While 97% of the women breast fed their last baby born in Indo China, only 22% breast fed their children who had been born in the USA. For those who did breast feed, the duration of breast feeding decreased from an average of 20.4 months in Indo China to 8.7 months in the USA. Reasons for the decline in breast feeding among the Vietnamese immigrants in the sample were the provision of artificial milk samples at the time of discharge from hospital, the women's limited knowledge and awareness of the advantages o f breast feeding for the babies and the mothers, and the conflict between their traditional practices and those of the host culture. In contrast with the above findings Reynolds et al (1988) indicated that there was no decrease in the rate of breast feeding among Vietnamese immigrants to Perth, Western Australia. They further suggested that the rate of breast feeding among these women was comparable with that of
Australian women living in the same city, 81% versus 82% respectively. Leininger (1988) explained that an individual's thinking, decisions and actions are guided by culture. Culture is the 'learned, shared and transmitted values, beliefs, norms and lifeway practices of a particular group of people in the society or environment in which they live (Leininger, 1988). T h e society or environment includes physical, ecological, social, emotional and cultural dimensions which interact to give rise to live experience. Upon immigration to a new country an individual's beliefs, values and life practices undergo modification and adaptation due to the environmental changes. This conceptual framework could be applied to the Vietnamese immigrants and their baby feeding practices. In order to reduce stress, and to prevent conflict and rejection from the host country, they learned to comply and adapt quickly to their new environment. T h e decision on baby-feeding practices was hence a process of adaptation (Leininger, 1987). Previous studies have demonstrated that physical, cultural and economic influences have affected the decline in the incidence of breast feeding among Vietnamese women following immigration to western countries (Mathews & Manderson, 1980; Henderson & Brown, 1987; Romero-Gwynn, 1989). However, there has been little study of how a new environment might affect Vietnamese women's decisions about baby-feeding practices. T h e purpose of this study was to discover Vietnamese women's attitudes towards baby feeding practices and to further explore the demographic, social, cultural and economic factors which might contribute to their abandonment of their traditional breast-feeding practices following immigration to Sydney. The assumptions upon which this study was based were that: 1) the demographic, social, cultural and economic factors were the predominant factors that influence the attitudes of Vietnamese women towards baby-feeding practices; 2) the process o f adaptation following immigration affected the Vietnamese women's decision concerning baby-feeding practices.
M1DWIFFRY
METHODS Since there was no existing tool available, a questionnaire and semi-structured, open-ended questions for interview were developed by the investigator. Both methods of data collection were used to increase confidence and validity in the findings. T h e items in the questionnaire and the open-ended questions in the interview focused on significant issues arising from the literature review and the author's previous pilot study to elicit: l) the participants' reasons for the choice of feeding method in Vietnam and in Australia; 2) the demographic, nutritional, cultural, socio-economic, body image and social support factors which might influence the decision of the baby-feeding method. Demographic factors included the women's age, place of birth, language(s) spoken, length of residence in Australia, marital status and n u m b e r of children in the family. Nutritional factors were assessed by the woman's knowledge and perception of breast milk and artificial milk. Cultural factors were raised by questions concerning maternal dietary preferences and restrictions related to breast feeding, other post natal behavioural practices and the perception of customary baby feeding practices in Vietnam and in Australia. Socio-economic factors elicited were income, education, and the e m p l o y m e n t status of the woman and her husband. Body image factors included her perception of lactation with her health, size of breast, attractiveness, embarrassment, fashion, work and social freedom. Social support and social influences were assessed by size and composition of the family household and assistance available. A Likert scale of five categories was used in the questions of nutritional, cultural, body image and social support factors to determine the opinion or attitudes of participants. In the interview the participants were asked 10 open-ended questions designed to probe their knowledge and attitudes concerning baby
105
feeding practices before and after immigration to Australia. Content validity of the questionnaire and the interview questions were assessed by two independent health scientists with expertise in the development o f questionnaires and maternal-infant nursing. Both the questionnaire and the interview questions were then translated into the Vietnamese language by a bi-lingual translator. T o ensure the accuracy o f the translation they were p r o o f read by independent professional translators. A pilot study, where 20 women received questionnaires and seven were interviewed, was conducted in early 1990 to determine the adequacy of the instrumentation.
Sample A sample of convenience consisting of 70 ethnic Vietnamese women whose ages ranged from 20 to 42 years (mean = 34 years) was recruited. All of them were born in Vietnam and married. T h e length of residence in Australia ranged from two to seven years (mean = 4.5 years). In order to compare baby-feeding practices, the women had to have had at least one child born in Vietnam and one child b o r n in Australia. Both babies must have been b o r n normally and at full term to eliminate poor baby physical condition as a basis for decisions regarding feeding method. T h e n u m b e r of children the women had ranged f r o m two to five (mean = 2.6). O f the 70 women, 43 were recruited through word of mouth or by knocking on doors in the Vietnamese area of residence around western and south western Sydney. Twenty seven were recruited from two Early Childhood Centres and a hospital maternity unit. T h e women were categorised into two major groups: 1) the breast-feeding g r o u p who breast fed both in Vietnam and in Australia (n = 47) and; 2) the artificial-feeding g r o u p who breast fed in Vietnam but artificially fed in Australia (n = 23). Each participant was provided with a questionnaire to complete whilst in the maternity ward, waiting in the Early Childhood Clinic for an a p p o i n t m e n t or in the participant's own
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home. Following the completion of the questionnaire interviews were conducted with 20 women who volunteered to participate. A research assistant who was fluent in both Vietnamese and English assisted the participants with the questionnaires and conducted interviews. All the interviews were conducted in the privacy o f the woman's home. Interview sessions averaged one and a half hours.
Data Analysis T h e quantitative data obtained from the questionnaire were analysed statistically, using frequency distributions, means and differences in proportions. T h e content o f qualitative data from large tracts o f verbatim interviews were tabled, interpreted and summarised. Selected aspects of the qualitative data are presented in this paper.
FINDINGS Baby feeding before and after immigration In Vietnam all of the 70 women had breast fed their children for a prolonged period. T h e length o f breast feeding ranged from 1 to 30 months (mean = 11 months). After immigration to Australia there was a sharp decline in breast feeding. Only 18 (26%) of these women breast fed exclusively, 29 (41%) breast fed partially and 23 (33%) artificially fed their Australian born baby. For those women who breast fed their Australian born baby, the duration o f breast feeding ranged from 1 to 18 months (mean = 6).
Socio-economic factors and their relationship to breast feeding Findings from the demographic and socio-economic data (Table 1) showed that 60% o f breastfeeding women were employed compared with 65% of those who artificially fed. However, more breast-feeding women (43%) than artificially feeding women (30%) h a d achieved an income in the range o f $ 2 1 0 0 0 to $30900 per annum. A higher percentage of husbands (83%) in the breast-feeding groups were employed compared with the husbands of the women in the artificially-feeding group (78%). Similarly, the husbands of the breast-feeding women (70%) earned a higher income than those who were artificially feeding (52%). In both groups of women the majority attended or completed their secondary education in Vietnam. Only 40% of the breast-feeding women initiated or attained their tertiary education in Vietnam but none of the artificially-feeding women achieved the same tertiary education. In Vietnam, the women lived in extended families and were guided by their mother or mother-in-law. Upon immigration to Sydney families decreased in size and changed in form. Some of the breast-feeding women (38%) had parents and/or parents-in-law living with them and 40% relied on friends for assistance. However, only 13% of the artificially feeding women had the same extended family life style and 57% relied on the assistance of friends (Figure 1). These findings suggested that women who completed a higher level of education, earned a higher income and who had a greater level of
Table 1 Comparison of the sociodemographic characteristics of the two groups of Vietnamese women in Sydney Variables Employment Income $20-$30,000/a Husband's employment Husband's income $20-30,000/a Women's tertiary education Extended family Dependent on friends
Breast feeding group (n = 47) N 28 20 39 33 19 18 19
% 60 43 83 70 40 38 40
Artificial feeding group (n = 23) N 15 7 18 12 3 13
% 64 30 78 52 13 57
Z Value
p
0.455 0.979 0.476 1.479 3.572 1.520 1.269
ns ns ns
ns p < 0.05 ns ns
M|DWIFERY
• Women from breast feeding group [] Women from artificial feeding group
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Fig. 1 Comparison of the sociodemographic data between the w o m e n in the breast feeding group and the
artificial feeding group.
assistance in the home were more likely to breast feed their baby in Australia. T h e husbands of these women were also educated to a higher level and had higher incomes than their wives. During the postnatal period, they, in turn, were looked after and guided by their mothers and mothersin-law. They were served with traditional postnatal diets to restore their health after childbirth and to enhance lactation. Upon immigration to Sydney, families decreased in size and changed in form. The women have no mother at hand from whom to seek advice nor to ask for help. They were exposed to a new and totally democratic society, the decision of baby-feeding methods was left to them and their husband. Some of the breast-feeding group (38%) had parents, parents-in-law, brothers and sisters or aunts and uncles living with them and 40% of these women relied on friends for assistance. However, only 13% of women in the artificially-
feeding group had the same extended family life style and 57% relied on the assistance of friends (Figure 1).
Factors w h i c h m a y influence baby feeding practices The cultural factors in the form of traditional customs appeared to be an important determinant of baby-feeding method when compared between the breast-feeding and artificially-feeding women. T h e majority of women in both groups (81% vs 83%) agreed that the availability of traditional foods in Vietnam was important to increase lactation (Table 2). Although the right choice of traditional foods was also available in Sydney there was a statistically significant difference in the proportion of women in the two groups who were given the foods in the
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postnatal period (83% vs 65%, z = 1.68, p < 0.05) (Table 3). T h e women found that without assistance at h o m e it was inconvenient to prepare these foods for themselves after childbirth, hence they opted for the alternative method of artificial feeding. In Vietnam, these women reported that they were able to breast feed because they were looked after (85% vs 87%) and assisted with household tasks by relatives (77% vs 70%). Since immigration to Sydney, their family structure had reduced to nuclear form; most women (45% vs 35%) were not being looked after by parents or relatives after their childbirth in Australia and they no longer received help with household chores (53% vs 35%).
T h e knowledge o f the nutritional value and benefits of breast feeding were examined. In Vietnam the majority o f both groups (94% vs 100%) agreed that breast milk had the right proportion o f nutrients that babies require (Table 3). Breast milk contained immunoglobulin to protect babies f r o m sickness (96% vs 87%). Breast feeding was natural (96% vs 96%), convenient (79% vs 83%), and hygienic (94% vs 92%). Nevertheless, the idea of breast feeding being convenient changed upon immigration to Australia (57% vs 35%) (Table 3). H a l f (51%) of the breast feeders and 65% of the artificial feeders believed that artificial milk was more nutritive and superior to breast milk. Some women (34% vs 48%) believed that artificially-
Table 2 Comparison of variables contributing to the decision of infant feeding practices in Vietnam between the women in breast-feeding group and artificial-feeding group
Variables
In Vietnam Breast feeding Artificial feeding group (n = 47) group (n = 23)
Z Value
p
Availability of traditional food Being looked after postnatally Assisted with household tasks Breast milk nutritious Breast milk protects infants from sickness Breast milk free of charge Breast milk natural
N 38 40 36 44 45 20 45
% 81 85 77 94 96 42 96
N 19 20 16 23 20 15 22
% 83 87 70 100 87 65 96
0.182 0.22 0.638 1.22 1.343 1.784 0.0194
ns ns ns
Breast feeding convenient Breast feeding hygienic Breast feeding facilitates attachment
37 44 41
79 94 87
19 21 22
83 91 96
0.383 0.366 1.10
ns ns p < 0.05
ns ns ns ns
Table 3 Comparison of variables contributing to the decision of infant feeding practices in Australia between the women in breast feeding group and artifical feeding group In Australia Artificial feeding group (n = 47) group (n = 23)
Breast feeding
Variables Availability of traditional food Being looked after postnatally Assisted with household tasks Breast feeding convenient Formula milk more nutritious Formula fed infant healthier Formula milk accessible Formula feeding not providing more freedom Breast feeding not embarrassing Breast feeding not old fashion Formula fed due to work
N 39 21 25 27 24 16 26 37 37 42 34
% 83 45 53 54 51 34 55 79 79 89 72
N 15 8 8 8 15 11 11 15 13 14 15
% 65 35 35 35 65 48 48 65 56 61 65
Z Value
p
1.68 0.784 1.44 1.31 1.123 1.114 0.984 1.21 1.932 2.79 0.6089
p < 0.05 ns ns ns
ns ns ns ns p < 0.05 p < 0.01 ns
MIr)WWERV 109 fed babies were healthier and fatter than breastfed babies. The women (55% vs 48%) also reported that the easy accessibility and relative cost of artificial milk in Australia was a factor influencing their decision to bottle feed. The notion of breast milk being free was significantly different between the two groups of women (Table 2). Only 42% of women in the breast-feeding group thought that breast milk was 'free' compared with 65% o f those in the artificial-feeding group (z = 1.784, p < 0.05). These latter women considered that the quality of a mother's milk could only be enriched by consuming a special diet which was costly. This negated the idea o f 'free' breast feeding to the majority of those women in the breast-feeding group. Factors relating to body image and attachment were also explored. Most women from both groups (87% vs 96%) agreed that breast feeding facilitated strong maternal-baby attachment. These women said they felt closer to their breast-fed babies. However, they also reported that artificial feeding did not lessen the dependency and demands the babies had on them. Similarly they (79% vs 65%) did not consider artificial feeding provided them with more freedom and time for other members of the family and housework (Table 3). Although most of these women in Australia agreed that breast feeding was not embarrassing (79% vs 56%) the difference between the two groups was statistically significant (z = 1.932, p < 0.05) (Table 3). The women in the artificiallyfeeding group considered that their breasts were too small to produce sufficient milk for their baby. They also perceived breast feeding as being unattractive and having an adverse effect on their health and figure. T h e r e was also a statistically significant difference between the two groups in the proportion of women who saw breast feeding as an old fashioned idea (z = 2.79, p < 0.01) (Table 3). Most of the breast-feeding women (89%) but only 61% of the artificiallyfeeding women agreed that breast feeding was not an old fashioned idea. Another reason for both groups of women (72% vs 65%) to select artificial feeding was that they needed to return to the workforce after
confinement. This need was economically motivated. In summary, Vietnamese women were more likely to breast feed after immigration to Australia if they had achieved a higher level of education, were provided with the correct traditional foods postnatally, did not think breast feeding was old fashioned and were not embarrased by breast feeding.
Qualitative data Qualitative analysis of the 20 in-depth interviews supported the quantitative findings. In Vietnam, the majority of women breast fed because it was the traditional thing to do. As most respondents explained, 'You see your mother breast feeding, and now its your t u r n . . , it just continued one generation after another'. Colostrum was believed to be 'stale' milk and should be discarded before the baby was put to the breast on the third postnatal day. One woman said ' . . . my mum taught us to use dates (the fruit) and rub it around the nipple to get rid of the old milk'. Traditionally, the Vietnamese believed that the health of postnatal women was weak and vulnerable. In order to regain their health, the women were required to observe postnatal rituals and dietary precautions. After childbirth the women were confined to bed for at least 30 days to avoid future health problems and to nurse their baby. Two respondents stated ' . . . my mum put me lying on the charcoal bed . . . it helps your womb contract back to normal...' ' . . . we did not have any shower straight away after c h i l d b i r t h . . , some may go as far as one month with having one shower o n l y . . . ' Dietary restriction was considered important to prevent maternal-baby illnesses and to establish lactation. A lactating woman should consume a specific high protein diet with a minimal
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etable intake to encourage milk flow and to balance both her and her baby's health. Most women interviewed explained, ' . . . definitely no sour tood, raw stuff like fruits and salads and coconut. They are very bad . . . . ' and, ' . . . my mum stewed pigs' trotters in pepper and lotus seeds or nuts for me to help my milk flOW
. . .'
It was the norm of the society that after marriage women did not return to work. Their duty was to remain at home to perform household work and to look after their children and family. During the postnatal period women were to concentrate on nursing their baby. They were, in turn, looked after by members o f their extended family. Some women reported 'I could breast feed my children because I did not have to go to work after m a r r i a g e . . . ' In Australia, these women experienced a complete change from their traditional customs in postnatal care. Babies were delivered in hospitals instead o f traditionally at home. In hospital, the women were required to get up for a shower soon after birth and to initiate breast feeding following delivery. For example, they were advised ' . . . to eat salad and orange j u i c e . . . ' , ' . . and to get out of bed and have 3 showers a day',
and ' . . to breast feed their baby as soon as s/he was born...'. Most of those interviewed had to return to work in order to assist in their family finance. Some women explained, 'It was convenient for me to bottle feed because I had to go back to w o r k . . . ' . For those who continued to breast feed in Australia it was reported 'I breast fed because I had unemployment benefit here and could stay at home l o n g e r . . . ' . With such conflicting differences between the old and new cultures, the Vietnamese women learned to adapt quickly to
the perceived ' n o r m ' o f their host country. They believed ' . . most Australian women bottle feed their babies because they have to go back to work •..'. Moreover, ' . . . powdered milk here has so much nutrition, not like those in V i e t n a m . . . I noticed my baby is a lot bigger to()...'•
DISCUSSION In this study a considerable decline in the rate and duration o f breast feeding has been demonstrated a m o n g Vietnamese women after immigration to Australia• T h e women who changed to artificial feeding in Australia were found to be from a lower socio-economic background, with a lower level of" education and a smaller income than those who breast fed. They had little support or guidance provided by family members to assist them with the traditional postpartum rituals in caring for themselves and their baby. These findings concur with the findings of Mathews & Manderson (1980), Henderson & Brown (1987) and Romero-Gwynn (1989). The findings o f this study differ from those o f Reynold et al (1988) in which no decline in the rate and duration o f breast feeding was found among the Vietnamese women in their sample. This may be due to sample differences. The women in their study were selected from a migrant hostel or shared accommodation with other Vietnamese families. Although the majority of those in Reynold et al's (1988) study had lived in Perth for 8 to 16 months, they remained in a close community network, maintaining traditional customs and baby-feeding practices. Thus, it is possible that the large majority o f those Vietnamese women continued to breast feed because of the strong community link; and they had not been exposed to the freedom and choice of artificial milk available in the host country. Findings from both qualitative and quantitative data in this study indicate that Vietnamese women's baby-feeding practices are shaped by their health beliefs: the beliefs about maternal health, about the baby's health and the family's health. These findings also suggest that both
MIDWIFERY 1 11 their baby-feeding practices and health beliefs are influenced by the social, cultural and economic factors o f their environment. T h e Vietnamese women believed that maternal health is weakened by childbirth. T o restore health, it is necessary for a w o m a n to follow the traditional postnatal rituals and dietary restrictions. A delicately balanced maternal diet is believed to enhance maternal and baby health and to encourage lactation. Vietnamese women consider babies are healthy if they are fat and putting on weight. Although it is agreed that breast milk is more nutritious than artificial milk it is said that the quality of breast milk is d e p e n d e n t upon the health of the lactating m o t h e r (Fishman et al. 1988). I f a woman is weak, suffering from any illness, taking medications or has had an operation, her milk is thought to be inferior and may transmit maternal diseases or health problems to her baby. In such instances the baby may often be artificially fed despite beliefs that artificial milk in Vietnam is poor in quality, expensive and not readily available. In Vietnam family health is based on the status, position and roles o f individuals in an extended family. T h e role o f a husband is to provide for the financial needs o f the family. A woman is expected to be a housewife and to care for her children and her elderly parents. She is not required to seek e m p l o y m e n t or to pursue her career once she is married. H e r mother or mother-in-law are usually involved in all the health care decisions of the family including the decision concerning baby-feeding practices (Rocereto, 1981). During the postnatal period, a woman is relieved of all household chores, including the care of her baby. H e r only responsibility is to breast feed her newborn baby. She is looked after and guided by her m o t h e r or mother-in-law and served with a traditional postnatal diet to restore her health after childbirth and to enhance lactation. Following immigration to Syndey there was a dramatic change in the social, cultural and economic environment for the women in o u r sample. Most of the women in the study became separated from their extended family. T h e y were therefore b u r d e n d e d with the responsibili-
ties of carrying out the day-to-day household tasks and had to make decisions, including the decision on baby feeding, for themselves without any guidance f r o m other family members. T h e problems were c o m p o u n d e d after childbirth in that they found themselves unable to follow the traditional postnatal ritual and dietary precautions without the assistance of their m o t h e r and/or mother-in-law. In order to establish a strong economic base for their family, most of the women were required to return to work soon after childbirth. Moreover the Vietnamese women believed that most Australian women bottle feed their babies and that artificial milk in Australia is superior in quality to that in Vietnam and to breast milk. In order not to further jeopardise their own health and their baby's health in future they abandoned their traditional baby feeding practices. Findings f r o m this study show some of the health beliefs of Vietnamese immigrants. T h e y also demonstrate how the social cultural and economic environment in Vietnam facilitate breast feeding. U p o n immigration, the traditional baby-feeding practices undergo modification due to the influence of the new environment. Artificial feeding is a 'forced choice' (Leininger, 1987) to maintain maternal and baby health while trying to accommodate the culture of the host country. Clearly, Vietnamese women experience social, cultural and economic problems of significant magnitude following immigration to Australia. These problems not only disrupt their lives but also motivate them to modify their cultural values. In order to be accepted and to survive in a new country Vietnamese immigrants, being pragmatists, are p r e p a r e d to adapt quickly to the perceived host cultures and practices (Leininger, 1987). Changing to artificial feeding is an adaptation process to the new environment, they believe, without too much compromise to their own health and traditional customs. Research has demonstrated the 'unique properties of h u m a n milk and the psycho-phsysiological significance of breast feeding' (Jelliffe & Jellife, 1978). Although the rate of breast feeding in Western countries has increased there is a considerable decline in the incidence and
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d u r a t i o n o f b r e a s t f e e d i n g a m o n g i m m i g r a n t s to W e s t e r n countries. I n line with t h e r e c o m m e n d a t i o n o f W H O (1981) t h e m a j o r goal in m a t e r n a l - c h i l d h e a l t h care is to e n c o u r a g e a n d s u p p o r t b r e a s t feeding. I n o r d e r to p r o m o t e a n d encourage breast feeding among immigrant women, it is strongly a d v i s e d t h a t t h e following r e c o m m e n d a t i o n s s h o u l d be c o n s i d e r e d a n d adopted: 1) It is crucial for midwives, h e a l t h c a r e workers, r e s e a r c h e r s a n d a c a d e m i c s to u n d e r s t a n d the social, c u l t u r a l a n d economic c o n t e x t o f the baby f e e d i n g practices o f i m m i g r a n t s . As stated by L e i n i n g e r (1984) a culturally sensitive a n d knowl e d g e a b l e m i d w i f e will receive m o r e positive r e s p o n s e f r o m the e t h n i c clients t h a n o n e who is not; 2) It is necessary to d e v e l o p e d u c a t i o n a l p r o g r a m m e s which a r e u n i q u e f o r a p a r t i c u l a r ethnic g r o u p . A u d i o - v i s u a l materials, videotape education programmes should be socially, c u l t u r a l l y a n d l a n g u a g e specific, a i m i n g to dismiss the m i s c o n c e p t i o n s conc e r n i n g b a b y - f e e d i n g practices in W e s t e r n countries. I n d i v i d u a l c o u n s e l l i n g a n d small g r o u p discussion p r o v i d e d by e t h n i c h e a l t h w o r k e r s a r e m o s t valuable. T h e use o f these e d u c a t i o n p r o g r a m m e s s h o u l d be m a d e available to schools a n d e t h n i c organisations in the c o m m u n i t y as well as in hospitals; 3) C o n t i n u o u s s u p p o r t a n d e n c o u r a g e m e n t o f b r e a s t f e e d i n g s h o u l d be given to i m m i grant women throughout their pregnancy, labour and puerperium; 4) B r e a s t - f e e d i n g c o n s u l t a n t services p r o v i d e d by midwives a n d h e a l t h c a r e w o r k e r s f r o m the s a m e ethnic g r o u p s in Early C h i l d h o o d C e n t r e s w o u l d be essential. 5) C u l t u r a l studies s h o u l d b e i m p l e m e n t e d in all m i d w i f e r y a n d n u r s i n g c u r r i c u l a in o r d e r to i n c r e a s e a w a r e n e s s o f cultural d i f f e r e n c e s , h e n c e to i m p r o v e t h e h e a l t h o f immigrants; Finally, it w o u l d be an i n n o v a t i v e c o n c e p t for La L e c h e L e a g u e I n t e r n a t i o n a l o r a n y association
f o r b r e a s t - f e e d i n g w o m e n to c o n s i d e r r e c r u i t i n g ethnic m e m b e r s to assist w o m e n f r o m various ethnic g r o u p s with b r e a s t feeding.
References Australian Bureau of Immigration Research 1988/89 Country of Birth and Settler Arrivals, Department of Immigration. Local Government and Ethnic Affairs, Canberra Fishman C, Evans R, Jenks E 1989 Warm bodies, cool milk: conflicts in postpartum food choice for Indo Chinese woman in California. Social Science and Medicine 26 (11): 1125-1132 Henderson A M, Brown J S 1987 Infant feeding practices of Vietnamese immigrants to the Northwest United States. Scholarly Inquiry for Nursing Practice 1 (2): 153-169 Hitchcock N E, CoyJ F 1988 Infant feeding practices in Western Australia and Tasmania: a joint survey 1984-1985. The Medical Journal of Australia 148: 114-117 Jelliffe D B, Jelliffe E F P 1978 Human milk in the modern world. Oxford University Press, Oxford Leininger M M 1984 Transcultural Nursing: an essential knowledge and practice field for today. The Canadian Nurse, Dec. 41-45 Leininger M M 1987 Response to 'Infant Feeding Practices of Vietnamese Immigrants to the Northwest United States'. Scholarly Inquiry for Nursing Practice 1 (2): 171-174 Leininger M M 1988 Leininger's Theory of Nursing: Cultural Care Diversity and University. Nursing Science Quarterly 1:152-160 Manderson L, Mathews M 1981 Vietnamese attitudes towards maternal and infant health. The Medical Journal of Australia 1: 69-72 Mathews M, Manderson L 1980 Infant feeding practices and lactation diets amongst Vietnamese immigrants. Australian PaediatricsJournal 16:263-266 Migrant Services Unit 1986 Communicating with Migrant Clients: A Training Kit and Resource Guide. Department of Social Security, Sydney Reynolds B, Hitchcock N C, Conveney J 1988 A longitudinal study of Vietnamese children born in Australia: Infant feeding, growth in infancy and after five years. Nutritional Research 8:593-603 Rocereto L 1981 Selected health beliefs of Vietnamese refugees. Journal of School Health Jan: 63-64 Romero-Gwynn E 1989 Breast feeding pattern among Indo Chinese immigrants in Northern California. American Journal of Disease Children 143:804-808 Rossiter J C, Ledwidge H, Coulon Let al 1990 The relevance of changes in Indo Chinese women's attitudes to breast feeding following immigration: a pilot study. Proceedings of Symposium: Reaching for Relevance. The New South Wales Nurses Interest Group World Health Organization 1981 Guidelines on Implementation of WHO International Code of marketing of Breast Milk Substitutes. WHO, Geneva.
