Assisting Refugee Mothers New to Australia with Infant Feeding Issues

Transcription

1 Assisting Refugee Mothers New to Australia with Infant Feeding Issues A guide for health professionals working with refugee mothers from Burundi, D.R Congo and South Sudan Background Breastfeeding issues are apparent in all populations and communities within Australia, but the nature of the issues may vary between community groups. Health promotion interventions need to be targeted appropriately for each different group. Every community has their own culture and language that needs to be considered when delivering health information to ensure that real changes are generated and that information given is appropriate and culturally sensitive. The benefits to health of breastfeeding are widely recognised and acknowledged. They go beyond solely benefiting the infant but promote both maternal health and psychological wellbeing i. The World Health Organisation has stated that appropriate feeding practices are of fundamental importance for the survival, growth, development, health and nutrition of infants and children everywhere. Some nutrients contained in breast milk are more bio-available, making them easily absorbed by the infant at a time when their bodily systems are immature and aren t functioning to their full capacity. ii Mothers from culturally and linguistically diverse (CALD) backgrounds are thought to have lower rates of breastfeeding than the Australian population. iii However, anecdotal reports indicate a more complex picture and contradict this finding for many of the newly arrived African migrants, coming to Australia under the special humanitarian programme. (Personal communication, Paediatric Refugee Clinic WA). The purpose of this background paper is to indicate some of the cultural beliefs, practices and norms that need to be considered when addressing breastfeeding initiation and duration within the Burundi, D.R Congo and South Sudanese refugee communities. The information included here has been gathered from interviews with parents and observations made over the course of the Good Food for New Arrivals Project. This information has been reviewed or cross checked for accuracy with community members and service providers working closely with this population.

2 Recommendations in Australia The National Health and Medical Research Council dietary guidelines recommend: Exclusive breastfeeding for the first six months; Complementary foods should be introduced at around six months; Breastfeeding should continue until twelve months of age and afterwards as suitable to mother and child; If breast milk is discontinued prior to 12 months, it should be replaced by commercial infant formula; When an infant formula is used, instructions for preparation must be followed precisely. Refugee Population from Africa in Australia The population of refugees arriving in Australia from Burundi, D.R Congo and South Sudan generally have a very strong culture of breast feeding. Many of these women have excellent knowledge and have breastfed numerous children over their lifetime. Information gathered from focus groups and interviews with these mothers has shown they have accurate knowledge about: the nutritional superiority of breast milk over formula the protective qualities of breastmilk against infection the importance of mother s diet for quality breast milk keeping good personal hygiene whilst breastfeeding the use of colostrum natural and expected it is not removed (but this may vary between tribal groups) The experience of migration may affect confidence in continuing what they know and believe to be appropriate. Additionally, the power and persuasion of western forms of advertising can have a strong influence on newly arrived communities. My second born was sucking my breast so much and I was not eating enough food, I felt so bad, I was so skinny to the point of stopping breastfeeding after 6 month. [sic] Babies are supposed to be given breast milk only from birth to bout 4 months because breastmilk has everything. Back home in Africa, if you don t give our baby with breast milk the baby will die because people don t have money for buying other milk. [sic] Breastmilk is good for child growth, protect the baby against diseases. [sic]

3 Considerations When Imparting Information on Commencement of Breastfeeding Reasoning behind not giving water to a breastfed baby needs to be clearly explained as this can be confusing for many women and result in distrust of hospital services and advice, if it conflicts with advice given previously. Breast milk, being 88% water, contains everything a baby needs to quench its thirst and satisfy hunger. Giving water can result in insufficient breast milk for nutritional needs and a decrease to milk supply. Encourage exclusiveunrestricted breastfeeding. Some women have reported they feel confused when asked their intention to breastfeed or bottle feed a newborn. They would not consider bottle feeding as first choice, and feel they are being encouraged to bottle feed when asked. Discussion around expressing breast milk and careful questioning to ascertain whether this would be considered appropriate for them and their culture, and practicalities of how to fit into lifestyle should be discussed. Discussion about their reasons for breastfeeding is helpful and they would benefit from additional information on topics such as contraception during this time; If not breast feeding, check that infant formula is being used and not just skimmed milk powder. Often family will use dried milk powder in preference to fresh milk. Ask about pictures on the tin or if the milk is special milk for babies or does the whole family use it? Greater detail may need to be gathered on volume and frequency of feeds if using inappropriate breast milk substitutes. Ask about the introduction of other foods and fluids Discussion around reassuring that sufficient milk supply is maintained to sustain the baby, can be helpful as for any breastfeeding mum. Early discussion around returning to English classes or work and how the infant will be fed during these times may be very useful. Discussing practicalities around how and when to express breast milk will be essential, if considered to be culturally appropriate. When you are pregnant they ask you whether you will breastfeed or not, I think this is not good according to our African culture. It discourages breastfeeding and makes bottle milk to have the same value with that of breast milk. [sic] The advice from hospital here is nonsense, they will tell you not to give your baby water (they told so to my friend), this is ridiculous, how can you do that! [sic] When I went to hospital in Australia, for delivery and they asked me whether I should bring the bottle for putting formula milk for my baby or if I can breastfeed, I told them I ve never do such a thing of giving my baby bottle milk, I ll breastfeed only. Immediately after giving birth I gave my baby breast milk. [sic]

4 Issues Arising Around Introduction to Solids Feeding practices for infants older than six months differ vastly between and within cultures. There are few rules regarding what is correct and incorrect practice. A balance between the information that is given in Australia as best practice, along with what is considered to be cultural practice, is required. Some issues where there is possible conflict in this population are considered here. Poor growth and failure to thrive may result from: Late introduction of any solids or any complementary foods Slow introduction of solids containing iron compounding iron deficiency anaemia Slow progression of textures Prolonged breastfeeding and 1-2 meals a day only given to child with breastfeeding all other times Risk of food being displaced by excessive fluid intake through: Introduction of additional fluids like tea and juice Night time feeding influencing ability/hunger for eating through the day Baby breastfeeding frequently for comfort Some of these issues may result from what is considered to be culturally appropriate for the infant and must be addressed with sensitivity. Economy of breastfeeding and food insecurity may also be influences on extended breastfeeding. When infant > 6 months old Check for introduction of solids At what age is it intended to introduce solids? Unlikely to use baby rice cereal fortified with iron as a first food Most likely to use weak maize/rice porridge with possible addition of flavourings, such as peanut butter or lemon, fruits or vegetables also used A maize or rice porridge can be an acceptable substitute, if used correctly and the diet contains sufficient iron sources. Unlikely to use baby food jars but in some cases there can be over reliance on these leading to slow progression onto the normal family foods and hence increase in textures given. Progression through textures can be slow, only offering a solid meal to baby twice a day and maintaining the soft and smooth texture for long periods without offering more lumps in meals Introduction of a bottle when coming off the breast may exacerbate problems around solids being accepted as the child finds it easier to drink.

5 Key questions How many times in the day does baby have something solid to eat? What is the texture of the food that you are giving? What foods are being used? Check for vegetables, starchy foods and meat or fish; Check how regularly solid foods are being offered throughout the day; Ask if the actual meat, fish or eggs are eaten or just the soup/stock of the family meals; Are baby food jars being used? If so, how many each day and how long are they stored once open? If baby rice cereal is being used, what other foods are intended to be offered and when? If homemade porridge is used, what is made from and what is added to it? If this is not the first baby, what foods would they have used at home? i World Health Organisation The Optimal duration of exclusive breastfeeding. Geneva: WHO ii National Health and Medical Research Council. Dietary Guidelines for Children and Adolescents in Australia, incorporating the Infant Feeding Guidelines for Health Workers, Canberra, 2003 iii Scott JA, Binns CW. (1998) Factors associated with the initiation and duration of breast-feeding. Australian Journal of Nutrition and Dietetics 55:51-61.

6 Barriers to Breastfeeding Exclusively or Maintaining Breastfeeding in Australia The research identified there are a number of barriers to breastfeeding in Australia for refugee women. Culturally, it is expected that breastfeeding will continue up until the child is 2 years old. Reasons for cessation of breastfeeding and other barriers include: Breastfeeding by Australian women is not highly visible in public, leading to perception that Australian women do not breastfeed; Time restrictions due to attending English classes or school; to the community; they became pregnant again. Each individual and community will have different barriers to breastfeeding and exploration of In Australian hospital they just weight me and took measurements. They didn t tell us about infant feeding. They just want to know whether I will be willing to breastfeed or give my baby bottle milk after delivery. I told them, I prefer giving my baby breast milk. [sic] Advice given in Africa, was that when babies reach 3 months, I can start giving other soft food like porridge. [sic] There are no advantages of bottle feeding but expressing breastmilk takes time and the use of a breast pump needs skills, so sometimes using bottle milk is better. [sic] There are differences between feeding here and in Africa. In Africa, women breastfeed more, but African women here tend to copy Western culture; they forgot our African culture of breastfeeding. In Australia people use more bottle milk, I think because they are busy working they don t have time to breastfeed. [sic]

7 Feeding Problems and Breastfeeding Issues Identified in Refugee Population There is insufficient data on breastfeeding exclusivity in the refugee population in Australia. Information gathered through the Good Food for New Arrivals project reports the following issues of which many are shared with the Australian born population: Breastfeeding to six months is not exclusive breastfeeding; Mothers feel it is insufficient to give just milk -water and other fluids often given additionally; Breastfeeding is used as the only way to settle baby-day and night; Iron deficiency anaemia is common in both mother and child; Vitamin D deficiency is prevalent due to deficiency in the mother; Prolonged breastfeeding due to: Inadequate safe food supply. Food insecurity Use as form of contraception. Cultural practice Introduction of solids prior to six months; Inadequate progression of solid textures, baby remains on smooth foods without lumps; Delayed introduction of iron rich foods like meat or fish; In some situations time economy - easier to bottle feed when caring for 4-5 other children and attending English classes My babies always are born with heavy weight, 5-6kg, Breastmilk only is not enough. After 2 months, I breast feed with other food for 2 years [sic] I give water during all time of breastfeeding, starting from the first month. [sic] Although these might be some of the issues experienced by this group, there is generally a good uptake of breastfeeding. It is considered to be the natural choice by most women and they would not consider bottle feeding if they have the ability to breastfeed. Past experiences and past history of poverty may have influenced their breastfeeding ability. The absence of normal support networks, such as extended family and community support, can also have a huge influence on a woman s ability to cope with breastfeeding.

8 This resource was produced by the Association for Services to Torture and Trauma Survivors (ASeTTS), through the Good Food for New Arrivals project. Good Food for New Arrivals is funded by the Australian Government. Find out where to access Good Food for New Arrivals resources at AUGUST 2008