At the Edges of Embodiment: Determinants of Breastfeeding for First Nations Women

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

Breastfeeding 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 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 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

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 <2 years old. Grandmothers and programmers participated as supporters to their daughters. Group sessions lasted 2–2.5 hours. A semistructured interview guide focused the discussions. Discussions were audio-recorded and transcribed verbatim. Analysis followed the qualitative methodological technique—with information coded, categorized, and then organized according to themes.

Results

Thirty-four percent of the participants were between 18 and 25 years of age, and 42% were between 26 and 34 years of age. Twenty percent were grandmothers. Forty percent of participants had graduated from high school, 18% had some high school, and 38% had some post-secondary experience (in a diploma or degree program). Eighteen percent of women had a household income in the range of $16,000–20,000, 15% had incomes of $31,000–40,000, and 46% had incomes of less than $16,000; 39% were receiving social assistance. Forty-six percent of the women were in a common-law relationship (in which the partner may not also have been the target baby's father), 25% were married, and 23% were not in a relationship. The overall mean age at first birth was 21.3 years, and 26% were teenage mothers. Mothers had from one to seven children. Thirty-one percent of women had birthed one child, 26% had birthed two children, and 17% birthed three children. Forty-five percent initiated breastfeeding with at least one baby, 23% initiated breastfeeding with two babies, and 15% tried with three babies. Eleven percent said they did not breastfeed any of their babies. Thirty-seven percent of the participants said they breastfed their babies exclusively for a period of time up to 6 months. Sixty-three percent reported using a breast pump, whereas 28% said they had not.

Three overarching themes were discovered in the research:

1. Social factors—including perceptions of self

2. Breastfeeding environments

3. Intimacy—including the contribution of fathers

Social factors

Incorporating public health and health promotion messages

Participant comments about breastfeeding often revealed an incorporation of public health messages into their thinking processes. For example, one woman explained: “I had fully committed to breastfeeding my daughter, as I know it is the best possible feeding choice.”

In response to the question, “What would you say if somebody asked you about breastfeeding? What advice would you give?,” women replied: “Try breastfeeding.” Even women who did not try themselves said they would advise other women to try to breastfeed: “At least try it.” Another explained, “If you can't actually breastfeed your baby, at least try pumping.”

Although most participants were health conscious and thoughtful about infant nutrition, some noticed that education about good infant nutrition was possibly not making its way to everyone. The following comments by women are examples:

…Carbonated drinks! Pop, right?…But I've seen it where some moms are just uneducated…

[Maybe] they don't realize that their baby's not gaining weight because of nutritional content …

Some babies that you just know are addicted to sugar.

Multiple responsibilities and pain altering the breastfeeding “ideal”

Women reacted to the idyllic images portrayed by the media and messages from public health and health promotion that breastfeeding was supposed to be a time wrapped in tranquility—a relaxed and effortless bonding between mother and baby protected from other responsibilities, stresses, and circumstances that surrounded it. In a reality far from the ideal breastfeeding scenario, women reported feeling pulled in multiple directions, attempting to balance infant feeding with care for older children, other family members, intimate relationships, house chores, and employment. Some mothers talked about urgent home repair issues, unemployment, poverty, relationship issues, violence and safety, loneliness, and other life crises. In a Manitoba regional evaluation of the Maternal Child Health Programs, the researchers discovered that many of these social and economic stresses—in particular, lack of or poor-quality housing, unemployment, drugs and alcohol, and violence—were endemic issues in many of the communities.²¹ These problems directly and more severely impacted the health of mothers and babies in the postnatal period and particularly affected comfort issues pertaining to breastfeeding and safety issues in bed sharing (co-sleeping), as will be discussed below. Several participants commented on the issues:

My concerns [were] about having no home and then no job, I just didn't breastfeed, so [pause] it's been a tough go.

[Breastfeeding] it's so not pretty.

Nobody really knows what it's like.

Everybody makes it so beautiful and it's just such an amazing thing to do and nobody tells you it's going to be like that. That's why, while the recorders on, that's how it is!

It's not like everything else around you stops and you can just breastfeed. It's dealing with everything at the same time. And the stress, it's just …

Education about breastfeeding made a difference to women's overall patience around the difficulties associated with beginning to breastfeed and to accepting the difficulties as a normal part of the process of finding comfort and ease. Not knowing what to expect, mothers said just trying to breastfeed and feeling its difficulty or discomfort caused them to give up quickly. Some were told that they could not return to the breast once they tried to bottle feed, as they understood that “nipple confusion” should be avoided. Most were not told that breastfeeding was an activity that would take some practice before a sense of comfort could be attained. Many said they were never told that it might take days before the milk would begin to flow. As a result, women said they either “had no milk” or lacked sufficient milk to satisfy their baby or that they “couldn't breastfeed”:

I guess I just wasn't producing, I mean, she'd be hungry after like 20 minutes.

So plus I wasn't sure like if there was any milk…I couldn't tell if she was even drinking right, because when I was breastfeeding her, yeah, milk was coming out but I don't know she wasn't probably not ever eating on it, right?

One of the participants said that a breast reduction surgery earlier in life left her unable to ever breastfeed: “I wanted to breastfeed, but because of the (breast) reduction surgery, all the milk glands were gone.”

Although there is no evidence of a relationship between breast reduction surgery and lactation and although many women, in fact, do breastfeed their babies after such surgery, this woman had been told that this was the case and therefore did not attempt to breastfeed.

Many of the women described excruciating pain with breastfeeding:

It was part of my birth plan to immediately start right after birth and until at least 3 months of age. But with the discomfort I couldn't.

I tried with all three of them, but it hurt so I stopped right away.

He was using his gums to pinch, and it hurts, so I stopped.

It's like your chest is being stomped on.

Yeah, it's really hurts.

Women discussed experiences with sore, cracked, and bleeding nipples, leaky breasts, engorgement, and mastitis. In some of the communities, the women did not know how to soothe these types of pains. Communities with lactation experts said they used nipple creams or tea bags to soothe cracked nipples. Many said they were unprepared for these kinds of pains.

Health promotion messages and, more so, peer support workers and home visitors had a great impact on women's education and, ultimately, their choice to initiate and sustain breastfeeding. It is important that the women emphasized a need for the messages to be more realistic than idyllic. They wanted to hear that it was normal to feel pain and to have to make several attempts before finding comfort and ease. Realistic education, in the end, fostered a greater likelihood that a woman would both initiate and sustain breastfeeding for at least 6 months. One woman said:

There's [sic] so many positives to breastfeeding but there's so much; not even my mom told me what to expect with breastfeeding. Like nobody tells you to expect certain things…like when the baby cries. You just leak like there's no tomorrow. Or if somebody's baby cries, you'll just start leaking.

Differentiating “learning” from “trying” to breastfeed

Participants distinguished between “learning” and “trying” to breastfeed. They said that breastfeeding, although a part of our nature, was not necessarily a behavior that was natural (i.e., that it was not something that came to us effortlessly). Rather, it was something both mothers and infants had to learn to do. Learning to breastfeed could take weeks, the women explained. The difference between “learning to breastfeed” and “trying to breastfeed” is something the peer support workers, home visitors, doulas, and lactation consultants teach in the programs. Learning implies personal agency. In learning, women actively work through breastfeeding, feeling their ways through to physical comfort and psychological or emotional connection. The quality of this conversation was very different from the above conversation that echoed public health messages. This conversation seemed to come more from the heart and from experiences with either trying and learning or giving up.

Risking self and womanhood for the sake of good mothering

In the focus groups, women discussed the stresses that came with the responsibilities of motherhood. Mainly, there were discussions about portrayals of “mothers” in the media or in official discourses as beings who were completely selfless, able to provide all to their families and to do so gracefully. Women also discussed messages that showed babies as having needs that were in conflict with the needs of mothers, therefore implying that the good mother would choose to fulfill the baby's needs by denying her own. Although some women felt this to be the case in their own lives, many of the women described the communities as being family-centric as opposed to woman- or nuclear family-centered, thus shielding them from the perceived battle to lose one's self for the sake of the baby. The following are examples from the conversations:

It's not about me anymore. It's about my baby, my uncle said to me. “More is expected from you in the family,” he said. Now you are part of the bosses, responsibility is greater, cooking meals, gatherings, dinners, you are expected to do more, to provide.

Sometimes I don't have time for myself, kids come first.

Postpartum sadness

Women in the groups discussed experiences of great sadness and loneliness postpartum. Some said they felt isolated and depressed, saying they felt there wasn't anyone around who understood what they were going through or what they needed to feel supported or understood. Some women said they felt these feelings contributed to their decision to quit breastfeeding earlier than they anticipated or to not breastfeed at all. Some of the comments are:

I just stay with my babies. All day long…they stress me out.

I'm going through stress right now. But I'm trying my hardest to be a good mother…

When [I feel] so scared, I, my anxiety attacks, I go outside and have fresh air until I calm down and I go back inside to my kids, alone.

I kind of felt like I was getting depressed or something because I felt so tied down and after I just put her on a bottle I just felt so relieved that I was not trapped anymore and I could just go. Like I'd bring [the baby] wherever I went but like at times my mom would take her and give me a little bit of time to myself.

The women described postpartum feelings as being more extreme than normal; for example, they described feeling depressed as well as elated. Although many of the women said they knew they could turn to either formal or informal (i.e., family or friends) for support, some said that it was difficult to find someone who understood feelings that they feared they were unable to adequately explain. Programs were cited as a place to go to for emotional support; however, most of the community-based maternity child health programs were not equipped with the kind of expertise required to deal with these issues. Of significant importance is that women who said they felt strong emotional support from their partners (i.e., baby's fathers) either did not report having postpartum depression or sadness or said that the feelings, although unusual, were not intolerable. Whether support came via formal or informal networks, emotional support seems to have made a greater difference than practical supports in easing the sadness.

Affordability of breastmilk and the high price of infant formula

Some of the First Nations created incentives to try and increase breastfeeding rates. Besides the intrinsic incentive—that breastmilk is free and requires no purchasing, preparation, or washing of bottles—women in some communities were given money by the band offices, if they chose to breastfeed exclusively. Breastfeeding mothers appreciated the incentives; however, mothers who were bottle feeding, whether because breastfeeding was seen as not a suitable or possible option for them, felt they were left unsupported. For this latter group of women, the high price of infant formula and, often, its nonavailability were constant concerns. Some of the comments from this conversation include the following:

Our bands would get us prenatal money just to, extra help out to, because you're breastfeeding so we got like, 40 dollars, every month for 6 months; some got longer if they were still breastfeeding.

I chose the breast because of the cost, especially when you are on EI [employment insurance].

My common-law just told me to breastfeed, “we can't afford both babies on formula.” Because I have three of them who are on a diaper still, three of them, and it's too expensive for us. That's why he's always out working…to support his babies.

Responding to agency of the babies

The decision to stop breastfeeding was not necessarily always the mother's. Women discussed babies' abilities to influence weaning, which sometimes led mothers to discontinue breastfeeding earlier than they would have liked or prior to the “optimal” time advised:

I stopped earlier than I thought because it was when [the baby] chose to stop.

Well, I stopped because they [my babies] stopped.

My babies made the choice.

I think for me, when I had my younger daughter, [my son] finally just quit on his own because he wasn't willing to share.

Considering attachment in relationship to feeding choice

Participants discussed their feelings about healthy attachment in relationship to infant feeding practices. Community and cultural norms regarding attachment and healthy maternal and child relationships also influenced the discussions. Much opinion among the participants supports a belief that breastfeeding encourages a better quality of attachment between mothers and infants, which affects their relationship over the lifespan. For example, women said:

I formula fed my first one and I feel more closer to her [nodding at second baby in her arms] because I breastfed her…

My second child, my daughter, I nursed her for over a year and she's 12 now. And she's very attached and it probably has a lot to do with nursing her.

I wanted that bonding thing that comes with the breast.

If you're a breastfeeding mother and you put your baby down for a nap you could be in any room of the house, I could be outside and all of a sudden it's like, “oh, the baby's up” without a noise. … The feeling like, “oh, there's the baby.” You know, it brings you a lot closer.

Participant mothers who were bottle feeding listened in on the conversations, but they did not let the conversation go unchallenged. Some mothers who bottle-fed their babies insisted it is the intention to be present and alert as a mother to the needs of her baby and not whether or not one was breastfeeding that made her more receptive and increased healthy attachment. For example, a mother said: “For me, it's that attachment, too. Even though I don't breastfeed. I'm still attached as if I breastfeed.”

The opinions of others in the family and in the community more generally about what constitutes health mother–infant attachment influence women's feeding practices and their comforts around feeding choice, as well as more broadly (i.e., in how they are to “properly” relate to their children) to raise healthy and yet independently secure children. The following excerpts are examples from the discussions:

My mother said to me, “If you don't get that baby off the boob nobody's ever going to be able to take care of it.”

That was my main concern because my nieces were breastfed and…you couldn't even babysit them for an hour and they'd be crying for their mom.

Since I lived with my partner and his family, they were happy that I finally listened to them and started breastfeeding ‘cause then my baby could bond with others too.

I could say I questioned myself hardcore on that one, when, with my son, because he was so stuck to me and he used me as a soother.

I think that stigma, that breastfeeding made a child clingy, really, really affected me. Did I cause him to be clingy? Did I do something to cut his freedom and make him overly dependent on me?

Ultimately in the discussions, women had come to share memories or stories about cultural practices and traditional norms. These discussions seemed to offer a level of normalization and acceptance of the values around mothering that they felt made the most sense to them. As one woman put the question, “Weren't these our values, to stay close to our children?”:

I totally agree, like I know what you mean!…We're being put, the societal ideals are being put on us. Your kids have to be outgoing and go out but if we look at that more from a cultural perspective, like we talked about, those rites of passage. These kids are [young], they are supposed to be beside their mothers and they're not to be out there with everyone else. So, you know, I think it's instinctive in us, but we always measure that as to what everyone else is thinking.

Community norms and public opinion

Attitudes and acceptances within communities affect women's feelings about breastfeeding. Where there is a greater acceptance and value upon breastfeeding, there is a greater likelihood women will sustain longer durations of breastfeeding and feel supported in their decision. Some communities are supportive of breastfeeding, educating mothers and bringing messages to community members via health promotion and traditional teachings. In one community, at the time of the study, there was a lively controversy regarding breastfeeding in public. Some community members, in particular, older members, thought it was “indecent” for a woman to “expose herself” in that way. Participants saw the controversy itself to be a sign of positive change because breastfeeding was now, at the very least, being talked about publicly. The controversy itself gave women the power to voice an opinion: “We're not ashamed now, so we will [breast] feed in public.”

Some quotes from the discussions on current public opinion and the belief that discomforts around breastfeeding emanate from a history of colonization and a loss of cultural traditions are:

The friends and the people that I was around they didn't think it was right [to breastfeed].

It wasn't common, we didn't, we just didn't breastfeed. It was, you know, it was a life of convenience. It was just that so much easier to make a bottle and rush out the door and away you go.

We were all bottle-fed ourselves around here.

I have the most embarrassing story about breastfeeding. [The baby] was like a month old and I was at the [X] community fair…and [the baby] needed to be fed so I went into the main, the one hallway area and I was feeding her but I didn't have, at that time, I didn't have a nursing cover and I was, well she was just a baby. … And, there wasn't much traffic there going through so…well I quickly fed her. And this guy he was…staring at me like, as I was feeding my baby. …

Sexual objectification of the feminine body

Tied to the “indecency” notion described above is the sexual objectification of women's bodies. Objectification theory postulates that women are sexually objectified and treated as objects valued for use by others. With sexual objectification, body parts are singled out or figuratively dissected from the rest of her person and her being and viewed primarily as an object of a male's sexual desire.²² The sexual objectification of women's bodies contributes to mental health problems among women, which begin as early as adolescence and even in childhood.²³ The consequences can be seen in a loss of a sense of self, lack of self-worth, eating disorders, anxiety, depression, self-harm, and suicide.²⁴ Much of the damage to mental health comes by an internalization of women (girls) of the views of others. It is important that, within our discussions, we found that sexual objectification impacts not only the mother's health, but also the health of her baby and the likelihood that the baby will receive what the mother “knows” to be the most nutritious food choice.

In the focus group discussions, women expressed feeling that others thought they were exposing themselves by breastfeeding in public or even in their own homes when others were also in the room. The women said that they were made by others to feel that breastfeeding is a rude or sexual behavior and that this caused them discomfort and constricted the space for breastfeeding to happen. One comment was: “[The baby's father] wants to support me but he's really uncomfortable; his mother says it's [breastfeeding is] gross.”

Although some of the women said they felt comfortable breastfeeding at home and in front of family members, others said that it bothered them to do so. A few of the women said it made their family members, including fathers, mothers, and mothers of the babies' fathers, feel uncomfortable. Some women shared that family members would tell them to “cover up” with a scarf or a blanket.

Women were critical about these attitudes and commented on the societal hypocrisy and mixed messages:

It's ok for girls to show them [breasts]…but oh no, don't show them when you're breastfeeding!

They [women] touch each other all over the place [in the music videos and at parties], yet breastfeeding is such a big issue!

Women included their opinions that cultural teachings provided an opposing message of acceptance: “Well these (breasts) were not toys when I was growing up. These were for food.”

The impact of residential schools

Residential schools' impacts on cultural loss, assimilation, and marginalization, as well as physical, sexual, and mental health consequences, are well known.²⁵ Women who attended the residential schools as students said they were taught to dissociate their minds from their bodies. Girls were taught their bodies were unclean and that they should cover up, keep clean, and then keep bodily thoughts away from consciousness. As a result, it was difficult or impossible to explore any sense of the body as an aspect of oneself or as a possible contribution of self to forming healthy relationships. In the words of the participants:

I was taught the body was dirty and that we shouldn't be thinking about it, or using it, or showing it.

As you know, I went to residential school, so did my mother and my grandfather; [as a result] none of us breastfed or were breastfed by our mothers. As for our traditions, I never knew them and so I couldn't pass them on to my daughters. But my daughter here is teaching them to me in the programs, I can see how it is that she is breastfeeding her baby. And I can see how much of the benefits are there for both of them.

Physical and sexual trauma

Experiences with physical and/or sexual abuse in childhood may have immediate as well as long-term implications to physical and psychological health and well-being, affecting conceptions of self, coping mechanisms, lifestyle, and parenting behaviors. Traumatic experiences at the residential schools as well as in the communities have had adverse intergenerational consequences. In Canadian indigenous communities, the long history of colonization makes the intergenerational impacts of physical and sexual trauma all the more notable.²⁶ The participants shared stories of childhood trauma. They also shared some of the stories they were told about their own mothers, fathers, and other family members of abuses experienced in the residential schools, at home in the communities, or as wards of the state (Child Welfare and Child and Family Services). The women talked about the damages that were done. Some described feeling that the experiences left them feeling “fragmented” as women, adding that it was difficult to fathom having healthy sexual relationships or perceiving one's body as being capable of nurturing or feeding a child. One of the participants captured the essence of the conversations with the following quote: “You can't teach about breastfeeding technique and think things will change. It's the spirit that's been affected, our experience with trauma. Our women need to relearn how to bond with their children.”

Breastfeeding environments

Co-sleeping and bed sharing

For at least a century, public health messages across Western societies regarding infant sleeping practices have adhered to the policy that babies should be provided a separate and distinct place to sleep. According to the Public Health Agency of Canada's policy on safe sleep:

The safest place for your baby to sleep or nap is in a crib, cradle or bassinet that meets current Canadian safety regulations. When babies sleep in places that are not made for them, such as on an adult bed, sofa or armchair, they can become trapped and suffocate. The risk of suffocation is even higher if a baby shares the same sleep surface with an adult or another child.²⁷

Public health messages regarding safe sleeping arrangements for infants cannot be regarded outside of the contexts of Western culture as well as the principles of scientific methodology. McKenna and McDade²⁸ described each of these circumstances in turn as the “good baby” ideal and refer as well to the rhetorical conclusions of “circular science” and “statistical illusion”:

When infant sleep studies were first undertaken using polysomnography the bottle fed, solitary sleeping infant became the gold standard method used to produce data on “normal” infant sleep physiology. [No]…cross-cultural or ethnographic data on more universal patterns were used as comparators. Instead, western social “folk” assumptions about what constituted healthy infant sleep were made, often based on moral justifications reflecting cultural ideas about how and where babies should sleep (relative to parents) in order to protect the husband-wife relationship and to produce psychologically healthy “independent” children. … Conceptions of what was in the best interests of infants medically found their way into moral characterisations of both the infants and the practices of parents who cared for them.^{28, p.136}

Scientists had set up the parameters for the studies to establish exactly what the studies were set up to conclude. There were no studies on the benefits of co-sleeping arrangements or qualities of ideal co-sleeping arrangements. Much less was there an interest on cultural ideals outside of the Western ideology. Furthermore, conceptions of mothers, femininity, and women in general seeped into Western reasoning, leaving women to embody exactly the perceptions that the Western world had of them. Women were regarded as dangerous to their babies, unconsciously capable of smothering them in their sleep.

Usurping the power of agency from women is a medicalizing and colonizing tactic that reduces (and may extinguish) a mother's trust in her instinctive abilities to raise her child and to choose what she feels is most appropriate to his or her needs. According to such reasoning, as mothers, not only do we lack the knowledge to care for our babies, more so, left to our own instincts, we might possibly kill them. Powerfully, McKenna and McDade²⁸ wrote:

[M]others' bodies, whether offering breast milk or not and independent of sobriety, continue to be regarded as potentially lethal weapons—wooden rolling pins, if you will, over which neither mothers nor their infants have control during sleep.^{28, p.135}

At the time of data collection for the current study, both First Nation Inuit Health of Health Canada and the Assembly of Manitoba Chiefs (the latter in its capacity as manager of the regional Strengthening Families, Maternal Child Health Program for the Province of Manitoba) had adhered to the policy written above: that the only safe place for babies to sleep was in a crib, cradle, or cot. Yet, arguably with a powerful resistance, or perhaps simply out of biological instinct, all of the women interviewed who were breastfeeding said they were also co-sleeping, specifically bed sharing, with their babies:

My babies slept with me all the time until two months old.

I don't know if my babies ever left my bed.

All my babies slept with me.

Mothers who were breastfeeding said they felt that bed sharing was conducive to breastfeeding. Mothers felt more secure waking up in the middle of the night and not having to get up to pick up the baby from a near-by cot or have to walk across the hall to a nearby bedroom. The mothers said the sleeping arrangement seemed to protect against accidents that could possibly happen with being tired. Mothers discussed feeling a bonding with their babies. They said they felt they would awaken easily, which also seemed to decrease crying. Participants agreed that co-sleeping was traditionally appropriate to indigenous cultures in all of the provinces:

It fits in with Haida (Gwaii) culture sleeping with babies.

Historically, as Anishinabe people, did we not all sleep in the same room? How have we come so far removed from who we are instinctively?

The mothers' intuition that the babies were safer in their beds is supported by the fact that most sudden infant death syndrome (SIDS)-related deaths or fatal accidents in Western countries occur “during solitary sleep outside the supervision of a committed adult.” McKenna and McDade²⁸ argued that in order to understand clearly safety and risk issues surrounding infant sleep practices, we must look further into the quality of the sleeping arrangements, spaces, and social circumstances:

[T]he overwhelming number of suspected accidental overlays or fatal accidents occur not within breastfeeding-bedsharing communities but in urban poverty, where multiple independent SIDS risk “factors” associated with bedsharing in high-risk populations are maternal smoking, infants placed to sleep on pillows or under duvets, with other children and co-sleeping with infants on sofas, waterbeds. … Bedsharing when the infant sleeps with an adult other than the mother, maternal exhaustion, alcohol or drug use, or leaving infants unattended on an adult bed also increase SIDS risk and/or fatal accidents.^{28, p.135}

Mothers who were bottle feeding may or may not have been co-sleeping (and bed sharing, in particular). The quality of the discussions was different in the two scenarios. Co-sleeping might have involved being tired and falling asleep on couches or reclining chairs. Discussions involving bed sharing among bottle-feeding mothers focused more so on limited options for sleeping in small crowded homes or not having a separate bedroom, crib, or cot for the new baby. These discussions, although they were also present in the discussions of breastfeeding mothers, did not include a focus on comfort, safety, convenience, and ease in bonding that the breastfeeding and bed sharing discussions contained.

Looking beyond co-sleeping and bed sharing to the quality of the sleep arrangements, as suggested by McKenna and McDade,²⁸ revealed many significant risks. Most of the risks are attributable not to the cultural practices of co-sleeping (and bed sharing specifically) but to the social and economic problems manifested by social inequity, colonization, and pervasive poverty.

Socioeconomic circumstances in many First Nation communities across Canada are dire, with poverty the norm. Co-sleeping for many of the mothers meant that mothers and their babies were sleeping in poor-quality housing that was often inadequately heated for the brutal cold of the Canadian northern winters and might also be infested with mold. Mothers described old beds with worn mattresses piled high with layers of blankets in order to shield off cold. Many of the women interviewed had other children who were also sleeping in the “family” bed, as well as fathers or male partners who were not the babies' fathers. Communal beds meant that people were coming in and out of the bed at different times and that there were additional blankets and pillows with which to contend. A few of the women described sleeping on couches, and a couple of the stories revealed that fathers too would at times sleep with the baby on the couch (i.e., as an effort to find a quiet space away from the family bed).

The participants in several of the communities and in more than one province discussed concerns regarding a seemingly increasing prevalence of alcohol and drug use in pregnancy and postpartum. Women spoke of a mixture that seemed to be increasing in popularity among new moms. The mixture was used as a method of releasing stress, a “letting go” both emotionally and physically. Women would concoct a mixture of two different over-the-counter prescription drugs to create what is appropriately called “numbs” or “numb-numbs” as a play on words that captures both elements of its use: a mixture used to calm a new mom, one that numbs both body and mind. The women said that this specific mix had become sought after for its ability to “make the body feel like it's paralyzed.” Participants were very concerned that new mothers were taking the mix while co-sleeping.

It is not clear whether women were able to distinguish between healthy and dangerous co-sleeping arrangements. They felt more comfortable and natural sleeping with their babies, and, perhaps, as the impoverished environment was the norm, it might have been difficult to know what kind of bed and bedding constituted a safe bed sharing structure. The focus of the discussion was that, “it's [sleeping with one's baby] a natural connection between mothers and their children.”

Smoking and breastfeeding

Discussions around smoking and infant health generally revealed that women were educated about the risks that smoking posed to infant respiration and the risk of SIDS or sudden unexpected death in infancy. Some of the communities had adopted policies or practices encouraging whole households to become smoke-free. Families would hang a blue light in the window to show the community that their home was smoke-free. Maternal–child health programs taught risks of first-, second-, and third-hand smoke.

Understanding the risks of smoking did not guarantee women would give up smoking. Some women shared their struggle to “quit the habit.” However, women would do what they felt they could do, which at times was to protect babies from what they believed to be “contaminated breastmilk,” choosing, as smokers, not to breastfeed:

I quit breastfeeding right away because of it [smoking], and [people said] “Oh, you should have stayed breastfeeding,” stuff like that. “That's healthy” and I was like, okay but I don't know, I wasn't sure because I was a smoker.

Discussions revealed that women who smoked were unlikely to breastfeed. Furthermore, as discussed above, women who bottle-fed were less likely to be bed sharing. Thus, it could be inferred that bottle-fed babies were sleeping in solitude and smoke-filled homes. As research indicates a strong correlation between smoking and SIDS or sudden unexpected death in infancy, this is an area in need of further research and education.²⁹

Evacuation for birthing practices

Much has been written about a “professional penetration and control” of pregnancy and, in particular, childbirth, as “essentially social and emotional events.” The medical profession's penetration and control of childbirth are marked for First Nation women living in remote communities across northern Canada.³⁰ Many policies eventually led to the practice of evacuating all pregnant women from their communities to tertiary-care centers for childbirth:

By the early twentieth century, the medicalization of childbirth in Canada, as elsewhere in the industrialized world, was well underway. As authorities became preoccupied with alleviating infant mortality and as overall health among aboriginal people deteriorated, an assimilationist policy was directed towards bringing childbirth among these women under direct government control. Subjected, simultaneously to ideologies of both gender and race, aboriginal people underwent a particularly stark transformation in their reproductive lives.^{31, p.400}

Women discussed at length the stresses caused by evacuation experiences. With evacuation, women are transported via flight, bus, or van from their communities at or prior to labor and brought to rest in boarding facilities (typically accommodations to support community members with medical appointments in the cities) until such time as they are ready to deliver their babies in the hospitals. Postdelivery, immediately or up to 2 weeks later, typically, women are transported back home. The entire process of evacuation can take from 6 to 8 weeks but more typically can occur in a whirlwind within 2 weeks.

Evacuation negatively impacted the likelihood of breastfeeding. Women explained that the process of evacuation—being away from home, the transience, uncomfortable accommodations of the medical boarding homes, a constant worry about families and other children at home, the stress of traveling, and lack of privacy or space to just relax and be with the baby—was not conducive to breastfeeding. Bottle feeding, under such circumstances, made more sense, and once women put the baby to the bottle, it was extremely rare for any to then return or go to the breast.

Women discussed the feeling that the nurses in the hospitals were pressuring them to breastfeed and shared stories where they felt the nurses were showing a lack of patience with them. It is understandable that if the nurses perceive their work to be about facilitating healthy latching that they would feel pressured to do so in the very short time that the women are in the hospital. The pressure on the nurses could quite easily and inadvertently be transferred onto the women:

It was a horrendous experience at [the hospital]. Because the milk hasn't come in yet the day of your baby delivery but they want you to latch right now. And they get so fussy.

I had a C-section and they told me that either I had to get my milk to come in right away or then he'd have to have formula. And I was in the hospital for five days with him and…They took him from me and fed him formula.

I was [too] tired and exhausted [to breastfeed].

Teen motherhood

In First Nation communities, the growing rates of teen pregnancy and parenthood, including very young teenagers, is a growing concern.^32,32 Participants discussed the challenges of breastfeeding to teen mothers, saying that most teen moms are unlikely to breastfeed. The reasons for their lack of interest centered on the emotional and social development of adolescents, such as body consciousness and an emphasis on peer connections:

It's one thing to get pregnant and another to expect a teenager to stay home and breastfeed her baby.

They want to go out…get back to the way they were [before the pregnancy].

Another issue affecting breastfeeding among teen mothers, as is true for all mothers, is the perceptions of others. For teen mothers, participants said that it was difficult to gain confidence when others were looking at them as incapable nurturers. It is very difficult to breastfeed when one is being judged as a young mother and far simpler to do the minimum required “so as to avoid attention from others.” A young mother would less likely be criticized or judged for bottle feeding than for breastfeeding—an activity seen as being within the realm of an older mother or a woman “old enough to be a mother”: “When you're young you can't do anything right, people are always telling you that.”

Informal and, more notably from the discussions, formal programming aimed to support teen pregnancy and parenting was successful in encouraging teenagers to breastfeed, for at least very short periods of time, for up to less than 1 month:

The teens could be supported within their community by their families as well as by programs. A lot of teen moms in [the community], with the right support and guidance, they can make it.

We have an education that brings children to school daycare program and that's good for teens in high school with babies, as long as they keep up with education and can support families.

If it happens it happens, but what's important is, are the young moms getting the support they need?

The contribution of the fathers

Recent research shows that involvement of fathers in breastfeeding matters does make a positive difference. Sharing the childbirth experience, mutual support between the parents, and sharing involvement in infant feeding practices were seen as positive factors associated with breastfeeding. Furthermore, paternal emotional, practical, and physical supports promote successful breastfeeding and enrich overall experiences for mothers and fathers.³⁴

Whether or not women were breastfeeding, there was consensus among the participants of the central importance of the fathers' support. Physical and emotional support from partners was pivotal in reducing stress and anxiety and fostering confidence and a sense of being valued (loved) among mothers:

It was difficult because he didn't agree with my vision. It [breastfeeding] wasn't something he was used to…he had never experienced it in his life. It wasn't something normal in his life. So there was an argument there because he thought raising a baby should be a certain way. A dad needs to bond too and he's seeing it like feeding is the only way to bond. And I'm trying to tell him, “While I'm feeding him, you can be right there. You can be looking in his eyes too.” It was just the whole convincing. I felt like I had to convince him that it was the best thing.

My husband was really upset that I wouldn't keep trying to breastfeed. He made me feel…I was upset and felt useless that I couldn't breastfeed.

Discussions showed that the paternal grandmother also had a great impact on breastfeeding comfort and success. Paternal grandmothers assist by educating their sons about pregnancy, childbirth, and breastfeeding and creating a greater feeling of comfort and belongingness within the realm of new parenthood. The more comfortable and supportive she was about breastfeeding, the more natural fathers felt in their roles.

The woman quoted in the following statement explains how it is that her partner is so very supportive of her breastfeeding: “In his family his mom taught him to help with the little kids and she is open with him about talking about you know, women things and even his own emotion.”

Discussion

The study explored some of the breastfeeding issues for First Nations women in Canadian reserve communities. Although most women were familiar with the public health messages that “breast is best,” many often found initiating and sticking with breastfeeding were often more difficult than they had expected. Notwithstanding physical pains of “trying” to breastfeed initially, women were emotionally affected by the opinions of others—whether these others were members of their intimate circles or were the unknown but judgmental gaze of the community public. Health policies and practices around childbearing for First Nations women in northern and remote communities affected breastfeeding. As well, women were influenced by interpretations of traditional practices. Moreover, the postpartum time included readjustments of self, body, and sexuality and a rebalancing of priorities to make room for women's responsibilities to self, sexual and emotional partners, family, and community. Issues explored in the study portray breastfeeding as a socially constructed event that is actively negotiated by women in their interactions with others from the most intimate to distal environments. Environments are shaped to either support or discourage breastfeeding. Public health and health promotion policies can be effective in promoting the social environment to be more supportive to breastfeeding. The following are specific areas wherein such policies can take shape.

Although breastfeeding was encouraged by the maternal and child health promotion programs in the communities studied, women in the programs were respected regardless of their infant feeding practices. Women who were bottle feeding their babies participated in the study and expressed issues surrounding their decision to bottle feed without judgment by the other mothers. This was significant, as inclusion of different feeding practices allowed for an exploration, within the programs and in the focus groups, of the quality of feeding practices, relationships, and the intentions or “mindfulness” behind the feeding practices. Breast might be considered to be best officially; however, the attitudes within the programs revealed that attachment, bonding, relationships, and positive social support were issues of greater value and import to facilitating wellness postpartum.

Some First Nations bands initiated policies to encourage breastfeeding. Encouragements were implemented as financial incentives to breastfeeding. Although the incentives were well intentioned—give money to women who were breastfeeding—they may inadvertently exclude a mother who could use the financial support who might for legitimate reasons be unable to breastfeed her baby. Discussions should take place at the level of the community, perhaps between programs and band offices, to find more effective ways to support breastfeeding.

Co-sleeping is a controversial issue. The Health Canada First Nation Inuit Health Branch and the Assembly of Manitoba Chiefs, for example, have officially stated that babies should not sleep in the same bed with mothers and/or other family members.²⁷ Rather, they specify, babies should sleep separately in cribs or cots. The dangers of co-sleeping have more to do with issues of poverty (e.g., soft mattresses, multiple persons sleeping in one bed, layers of blankets and pillows) and with mothers' use of drugs and alcohol. The evidence does not show a direct correlation between co-sleeping and SIDS, but with these other co-variables.²⁸ Bed sharing, a particular kind of co-sleeping arrangement, increases likelihood of breastfeeding and strengthens the maternal–infant bond.³⁵ However, when a mother is using alcohol, the same is not true.³⁶ It has been shown that breastfeeding reduce the incidence of SIDS.³⁷

First Nations traditional practices included co-sleeping as a healthy and essential aspect of secure development and facilitating of a healthy attachment between mother and baby (the tradition extended to both parents). In our study, we found that mothers who breastfed were also bed sharing. Mothers reported feeling safer with the baby in their beds, rather than having to walk in tiredness to another bedroom in the house to pick up the infant for a feeding.

In the communities studied, most homes did not have enough bedrooms to put the baby in a separate room. Inadequate heating meant that mothers had to add layers of blankets in order to keep warm overnight. Poverty meant that people were often sleeping on old and soft mattresses or lacked enough beds to accommodate all of the members of the family. Multiple socioeconomic stresses compounded the risks.

To keep babies safe, health promotion messages focus on a message discouraging co-sleeping. This is because it is easier to send out that message than to attend to the complexity of the issues involved or change social and economic policies for the creation of a more equitable world. More work needs to be done to attend to the complexities involved in infant sleep environments. The policies need to reflect cultural values around maternal and paternal bonding as well as to the quality of environments and overall social and economic conditions under which babies are raised. In the meantime, the Assembly of Manitoba Chiefs has been working on a campaign that encourages women to place their babies to sleep in a separate cot but next to the mother's bed. This is an understandable compromise that places the baby's well-being as a priority within socioeconomic and political realities that are far less than ideal.

Smoking prevalence and incidence rates among First Nations women are increasing within the communities and are higher in comparison with the rest of Canadian women.^38,39 As well, rates within the communities are higher than for non–First Nations Canadian communities. As such, mothers are susceptible only to the health impacts of first-hand smoke, and babies are susceptible to the impacts of second- and third-hand smoke. Community-based maternal and child health promotion programs encourage women not to smoke in pregnancy. However, the study findings show that women are requiring more support prenatally to quit smoking. Often women have started smoking in adolescence or childhood and have formed habits difficult to break. First Nations communities can support childbearing women by speaking about the health and social implications of smoking in community settings and in the schools (before children have picked up the habit).⁴⁰ Smoking should be discouraged from public places.

Medical evacuation of First Nations women away from home communities to deliver babies in tertiary centers hundreds of, even a thousand, miles from home is problematic.⁹ The practice, although not an official policy, affects nearly all of First Nations women in the communities studied. Although home birthing is an option incorporated into some of the communities across Canada, most women continue to be evacuated.⁴¹

Evacuation discourages breastfeeding. Even well-intentioned women “gave up trying” as the evacuation experience caused extreme stress and disruption in its transience and dislocation of women from home and family supports. Hospital staff members are pressured into trying to get the baby to latch on so quickly that women give up in frustration. To encourage successful, long-term breastfeeding, hospital staff might do better to teach breastfeeding skills not expected to be incorporated until after women have returned home.

Community-based maternal and child health promotion staff and nurses can work together to share a protocol for positive support of women over the transience of the evacuation time. Programmers and practitioners need to be educated about the stresses and discomforts of evacuation in order to increase overall effectiveness of support and increase the likelihood that a woman will breastfeed once she returns to the comfort and security of home.

Residential schools have left wicked scars on student bodies, scars passed on intergenerationally and that have sometimes been transferred in physical and sexual violence within the communities. Trauma dissociates women from self and body and interrupts breastfeeding. The women in the focus groups discussed a need for a trauma-informed breastfeeding support strategy. This is an area for exploration within the communities, as well as within government and universities.

Traditional teachings complement breastfeeding supports. Women found meaningful guidance within traditions. A greater focus on tradition and cultural exploration is conducive to maternal, infant, and family wellness. Furthermore, women's decisions or comfort around breastfeeding is affected by the opinions and attitudes of others; therefore, it is beneficial for public health and health promotion messages to be inclusive of family and communities. Support programs help women through relationship stresses. Programs can be influential in this regard, as women indicated support of staff, particularly lactation consultants, as pivotal to continuing breastfeeding.

Universal breastfeeding support programs are effective in increasing breastfeeding initiation and duration rates. But also, targeted breastfeeding supports for specific populations (i.e., teen mothers) are recommended. The women discussed the problems that an idealized image of breastfeeding was having on them. More realistic teachings about what to expect in breastfeeding might actually better prepare women for the challenges of breastfeeding.

Within environments of ambiguous or, at times, judgmental or negative public opinion, paraprofessional peer support (in the form of the maternal–child health program “home visitor,” doula, or lactation consultant) relations help in increasing the likelihood that a woman will successfully breastfeed her child and that the duration of breastfeeding will increase to at least 6 months. Paraprofessional peer support in the postpartum period helps to reduce feelings of social isolation.

The findings from this study should help public health and health promotion practitioners as well as traditional teachers and First Nations community leaders to implement more supportive breastfeeding messages, programs, and policies within the communities. The findings point attention to the social determinants of breastfeeding and thinking about breastfeeding. The study contributes to the literature in its exploration of the specific circumstances of First Nations women and their relationship to breastfeeding. In particular, inequitable social and physical worlds are embodied and are revealed in breastfeeding behaviors. Breastfeeding unfolds for women in their social and physical interactions.

Footnotes

Acknowledgments

Thank you for the support from First Nations across Canada and to the First Nation Inuit Health Branch of Health Canada, for funding the study.

Author Contributions

R.E. and W.P-B. were primarily involved with conception, design, analysis, and interpretation of data, drafting of the manuscript, and revising for important intellectual content and gave final approval of the version. P.M. was primarily involved with drafting of the manuscript and revisions for intellectual content. All authors take public responsibility for appropriate portions on the content. All authors read and approved the final manuscript.

Disclosure Statement

No competing financial interests exist.

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