Mothering at the Intersection of Marginality: Exploring Breastfeeding Beliefs and Practices Among Women From Nova Scotia,Canada Who Identify as Overweight,Low Income,and Food Insecure

Abstract

Breastfeeding is represented to support healthy body weight and food security. However, breastfeeding may be negatively impacted by high maternal body weight and income-related food insecurity. Guided by feminist poststructural methodology, this study explored breastfeeding beliefs and practices among women from Nova Scotia, Canada, identifying as income-related food insecure and overweight. Participants who were pregnant for the first time and intending to breastfeed participated in three interviews: prenatal (n = 8), first month postpartum (n = 6), and 3 months postpartum (n = 6). Employing discourse analyses, we found that participants’ experiences aligned with dominant discursive representations of these health issues, informed through normative understandings of what it means to mother. However, some participants resisted and reframed what constitutes good mothering to identify with maternal subjectivities that were context specific. The findings have implications for understanding how discourses shape maternal identities and their effects for breastfeeding and other health-related practices.

Keywords

breastfeeding women’s experiences feminist poststructural methodology health practices income-related food insecurity obesity maternal subjectivity discourse analysis qualitative interviews Nova Scotia Canada

Introduction

Breastfeeding is well established as the normal, healthy, safe way to feed an infant (World Health Organization, 2019) and is represented as a population health strategy supporting food security (van Esterik, 2019) and healthy body weights (Victora et al., 2016). Contemporary breastfeeding policy is largely aligned with evidence associating breastfeeding with health benefits for infants, mothers, and the larger community. The majority of Canadian mothers initiate breastfeeding (Statistics Canada, 2012); however, continuing to breastfeed exclusively or at all remains a challenge for many (Statistics Canada, 2012, 2019a) including those experiencing income-related food insecurity (Frank, 2015a; Orr et al., 2018) and/or excess maternal body weight (Amir & Donath, 2007).

Varied explanations for the cessation of exclusive breastfeeding include physical discomfort and/or fatigue and perceptions concerning maternal milk supply or infant satiety (Ahluwalia et al., 2005; Li et al., 2008; Odom et al., 2013). An emerging area of research is the cessation of breastfeeding in relation to high body weight. Rasmussen and colleagues were the first to observe that pre-existing high maternal body weight or excess gestational weight gain negatively influences breastfeeding outcomes through the lactogenesis II pathway (Hilson et al., 2004, 2006; Rasmussen et al., 2001, 2002). Latch and positioning difficulties are experienced among women of larger body size in both private and public spaces (Claesson et al., 2018; Garner et al., 2017; McKenzie et al., 2018). Bias and stigma toward those with high body weights (Puhl et al., 2015) impact their perceptions of self and identity (Himmelstein et al., 2017) and relationships with health professionals from whom infant feeding support may be sought (Phelan et al., 2015); multiple stigmas may also be at play with the intersection of weight, socioeconomic status, and gender (Makowski et al., 2019). Furthermore, there is a lack of understanding among health professionals about the unique breastfeeding challenges that may be experienced by mothers with higher body weights (Garner et al., 2014).

Breastfeeding practice occurs on a social gradient where those most likely to adopt breastfeeding recommendations have higher incomes and education (Frank, 2015b; Orr et al., 2018). Low income is strongly associated with household food insecurity, and food-insecure women, including those of childbearing age, are more likely to experience higher body weights (Laraia et al., 2010; Townsend et al., 2001). Therefore, it is possible that the lived experience of both food insecurity and high maternal body weight might provide some explanation for why any or sustained breastfeeding is less likely to occur. Understanding a person’s beliefs, values, and context in relation to these interrelated health issues is a critical step toward applying a person-centered approach to establishing and maintaining a breastfeeding practice within socially disadvantaged populations (MacVicar et al., 2015).

Research Purpose

Inequities in infant feeding practices that exist between population groups represent an issue of social justice (Zamora et al., 2015). While evidence suggests that breastfeeding outcomes are affected by high maternal body weight and income-related food insecurity, this is known to be the first study to explore the intersection of these issues using lived experience. Specifically, the objective was to examine how participants experienced breastfeeding within the additional contexts of high body weight and food insecurity by attending to participants’ construction of discourses relating to these topics.

Methodological Approach

This inquiry was guided by feminist poststructural (FPS) methodology and the philosophical concepts of scholars including Foucault and Scott (Scott, 1988, 2013). An FPS approach contextualizes and explores experience through a socially, historically, and politically centered understanding of language giving rise to “knowing” or “truth” (Weedon, 1996). Within an FPS approach, discourse theorizes power and its effects through the use of language—understood as a “system always existing in historically specific discourses” (Weedon, 1996, p. 23). Discourses define the limits of what is and can be said at a given time and place and with whom (context), enabling people to think and shape meaning from their experiences in particular ways (Mills, 2004, p. 7).

This framework for power and language is a useful means of exploring how discourses are negotiated in society (relations of power) as they not only shape meaning for individuals but work in broader networks to affect the organization of health and related social institutions (Weedon, 1996, p. 105). Varying discourses compete for legitimacy resulting in some becoming dominant while alternatives are positioned as “other” or are rejected. This is problematic insofar as the potential for discourse to create a “partial and misinformed” perspective of experience by “silencing alternative ways of understanding health” (Travers, 1995).

Consistent with FPS methodology, a feminist approach was employed (Hesse-Biber, 2014) in this study. It was informed through the seminal work of Oakley (1981) and Rossiter (1990). A feminist research practice transforms knowing from a positivist-centered inquiry to one in which knowledge is understood as context-specific and relational (Hesse-Biber, 2014; Lather, 1991). To this end, “experience” is the focus of inquiry to delineate understandings of social reality (Scott, 2013); feminist research focuses on understanding “experience” through multiple points of intersection, positionality, and contestation (Hesse-Biber, 2007). Foucault’s decentred subject and plurality of identities created through exposure to discourses enables the exploration of agency in health-related practices (Ramazanoglu, 2002).

Research Approach

Setting

The study took place in Halifax, Nova Scotia, Canada, home of the largest birthing center in this region (IWK Health Center). Nova Scotia is ideally positioned for this exploration as women from this province report both high maternal body weight (Woolcott et al., 2016) and some of the lowest rates of breastfeeding initiation and duration in Canada (Al-Sahab et al., 2010), while Halifax consistently reports among the highest incidence of income-related food insecurity in the country (Sriram & Tarasuk, 2015).

Ethical Considerations

This study was approved by the IWK Health Centre Research Ethics Board (protocol #04506).

Participants, Recruitment, and Study Enrollment Process

Participants were purposively recruited for their ability to narrate their experience of breastfeeding practice within the discourses of pregnancy, new motherhood, high maternal body weight and income-related food insecurity. Participants identifying as “intending to breastfeed” and meeting additional inclusion criteria (Table 1) were invited to participate. The process for participant recruitment was iterative and employed several strategies because of challenges affecting research participation among underrepresented populations (Ellard-Gray et al., 2015; Joseph et al., 2007). Recognizing the importance of engaging with health professionals who might provide direct care and support with the population of interest (McMillan et al., 2009), the process for participant recruitment began at the perinatal center of the IWK Health Centre. The primary researcher engaged with managers and staff regarding the study, and study recruitment posters and postcards were placed throughout the perinatal center. In addition, recruitment posters and postcards were distributed to family resource centers and health clinics with a specific focus to serve underrepresented and socially disadvantaged communities. Study recruitment information was also posted on Kijiji Halifax (an online classified site for exchanging products and services) for widespread recruitment purposes. Sixteen people expressed interest in participating—nine of whom met the inclusion criteria; eight participants were enrolled after providing written informed consent. Of the enrolled participants, six completed the study (three interviews each). We did not purposefully recruit participants based on diverse geographical, cultural or other situational contexts. However, in recognition that discourses produce and are reproducing within varying milieu, any contexts and exposures disclosed by participants during data collection that were related to geographical, cultural, or situational contexts were considered throughout analyses.

Table 1.

Study Inclusion Criteria.

• Resident of [province of study]
• 18 years of age or older
• Pregnant with first (singleton) baby
• Stated intention to breastfeed
• Pre-pregnancy BMI 27 kg/m² (lead researcher calculated based on self-reported height and weight)
• Monthly after-tax household income disclosed at or below LICO cut-off (based on the number of household occupants and postal code identifier; Statistics Canada, 2019b)
• Responding either “sometimes true” or “often true” to the following two statements: (1) Within the past 12 months we worried whether our food would run out before we got money to buy more and (2) Within the past 12 months the food we bought just did not last and we did not have enough money to get more (Hager et al., 2010)

Note. BMI = body mass index; LICO = low income cut-off.

Data Collection

The primary data collection method for this study was face-to-face, audio-recorded participant interviews supplemented by field notes that captured nonverbal cues and additional contextual elements. An FPS perspective retains the plurality of experience, and these were considered to be partial and potentially shifting. A repeat-interview structure was deliberately employed not only to strengthen trustworthiness, but also to recognize that the experiences of breastfeeding, income-related food insecurity, and maternal body weight are dynamic and shaped through temporality. Participants were interviewed at three time points: after their first trimester of pregnancy (n = 8), 1 month after giving birth (n = 6), and 3 months after giving birth (n = 6). All participants experienced full-term births and all reported that they initiated breastfeeding. Data collection occurred from January 2014 to May 2015 and interviews averaged over an hour in length. Each participant was provided a cash honorarium of CAD$25 per interview.

Interviews focused on conversational dialogue and interaction between the primary researcher and participants as part of a co-constructive, sense-making activity. A semi-structured interview guide was used to allow for flexibility in the discussion about the expectations and experiences of breastfeeding, food insecurity, and living with higher body weight (Supplemental Material). This interview approach helps situate the participant and researcher as subjects producing knowledge about that experience (Gubrium & Holstein, 2003, p. 74). We used “markers” as an active listening exercise (Hesse-Biber, 2014). Probing questions were used (e.g., “You just mentioned. . . Can you tell me more about. . .?” or “How does. . . make you feel?”) to elicit further information about their experience; field notes captured the interview tone and emotions elicited.

The interview is also a site of discursive formation and reformation, and this formed part of the analysis and interpretation, rather than analyzing solely the narratives provided by the participant (Gubrium & Holstein, 2003). The interview style helped to examine both what and how the participant experienced the subject matter under investigation, allowing for a more in-depth narrative of the experience to be revealed within analyses and interpretation. The active interview approach also supported researcher reflexivity and an examination of how this positionality was shaping the interview process.

Data Analysis

Audio-recorded interviews were transcribed verbatim and all data (the interview transcripts and field notes) were analyzed iteratively and informed through Foucauldian and feminist discourse analysis methods outlined by a number of scholars (Aston, 2016; Jager & Maier, 2009; Mills, 2004; Rose, 2006; Willig, 2013; Table 2).

Table 2.

Approach to Data Analysis.

Activity	Rationale
1. Verbatim transcription of audio-recordings	Initial interpretations; attendance to how topics were discussed (emphasis, tone of voice); supplemented with field notes
2. Detailed, line-by-line read of transcripts for key words, themes, repeated structures, and statements	Identifying discursive constructions of topics under exploration; identifying discourse fragments, collective symbols, and discourse position (Jager & Maier, 2009)
3. Team meetings	Reviewing emerging discursive constructions; discussing how interpretations were similar or different and the process for moving forward with the remaining analyses
4. Identifying the action orientation of discourse (Willig, 2013)	Interrogation of the use of language—emerging patterns, words, themes, and subject positions; how subjectivity is constructed through the exposure to varying discourses; how discourses relate to legitimizing actions and practices
5. Contrast and variation across texts	Attending to the invisible (unseen or unsaid), and differences and tensions that existed between constructions of discursive objects
6. Identifying dominant discourse strands	The completeness of the discourse strand is apparent if no new arguments become present

Trustworthiness

The repeat-interview structure strengthened credibility of the findings enabled by repeated engagement between the primary researcher and participants, immersion in the research setting, and triangulation of data. The multiple data points provided the opportunity for an in-depth exploration of the topics of inquiry; researcher field notes and initial interview codes were used to revisit topics and provided an ongoing opportunity for clarification and enhanced credibility for the perceptions and experience as articulated by the participants. Credibility was also enhanced through ongoing discussions among the research team regarding emergent findings and the analytical approach. These discussions focused on the emerging discursive constructions and discussed points of similarity and difference in the interpretation of findings. Interpretive rigor was supported through the use of in-depth descriptions of experience and using exemplar quotes to support findings. An audit trail detailing the research process and approach to analysis was used to support dependability of the findings. The primary researcher (S Meaghan Sim), who identifies as a health professional, participated in an ongoing process of journaling and exploring both researcher-position and taken-for-granted assumptions. This reflexive practice helped to maintain an ongoing focus on positionality throughout the study.

Findings

The societal discourse on “good mothering” was fundamental to participants’ experiences as both pregnant women and as new mothers. This discourse both prioritizes the needs and protection of children while identifying and reinforcing normative roles of mothers as primary nurturers and protectors (Marshall et al., 2007) and is reified through institutional interactions and practices.

Maternal Bodies: Am I Fit to Breastfeed?

Participants consistently aligned their experiences and beliefs about the health topics under exploration with normative understandings of mothering and an essentialist perspective of the (maternal) female body. All of the participants spoke of their desire to breastfeed through their belief that breastfeeding was the most natural and healthiest way to nourish their babies, while formula was represented as an unaffordable and less-suitable alternative (“[formula] seems so artificial”). Breastfeeding represented mothering in a good and proper way; by breastfeeding, participants would be giving their babies the best possible start in life. Consistent with their beliefs about the importance of breastfeeding, each of the participants initiated the practice after giving birth.

Breastfeeding was also consistently positioned as a taken-for-granted practice associated with an ideal maternal body; statements made included “You breastfeed your child—that’s why your body works, that’s the way . . . mother nature works” and “I assume [breastfeeding’s] just gonna work . . . that it’ll be innate and instinctual and natural . . .” The physical body, thus, was a discursive site for reproducing the good mother subject. Throughout the interviews, participants’ statements conceptualized an ideal physical maternal body as one that was youthful, clean of drugs (prescription or illegal), and without pre-existing health conditions. One participant suggested that living with both a chronic condition (diabetes) and food insecurity would negatively impact breastfeeding success:

What if I don’t have enough milk produced for him to eat? Being a diabetic I worry about that . . . after he’s born, am I still going to be a diabetic? And is that going to transfer through to my milk? What I have to eat—am I going to be able to get enough nutrition to be sufficient for him?

The experience of living with income-related food insecurity and high body weight also added to participants’ construction of the ideal physical maternal body as being well-nourished and of “normal” shape and size (including breasts). Participants shared the perspective that excess maternal weight was a failure on both personal and moral levels, and this was implicated in breastfeeding practice. One described this as “My weight most affects me by actually being weight . . . it literally weighs me down [mentally]. . . . It affects my self-image . . . it affects self-esteem . . .” Several participants acknowledged that maintaining their weight within the normative standard was challenging under resource constraint; unhealthier foods of minimal quality were frequently consumed and were useful for feeding, but not nourishing, the body. Stated one participant: “I never seem to have enough good food. The food that I have is crap . . . therefore, I feel like crap and, therefore, I look like crap . . .” When asked about the relationship between breastfeeding and her ability to afford foods, one participant replied,

What I think and believe . . . is that my proper nutrition is going to go into my breastmilk to my baby . . . so if I’m not feeding myself properly, then my baby’s not getting as good nutrition as possible.

Another stated, “I don’t eat . . . the way normal people eat . . . I didn’t even think of factoring that into my ability to breastfeed.” In later interviews, a participant described how both her body weight and food insecurity was influencing her breastmilk:

I was worried about whether or not she was getting the proper nutrients and things like that . . . but I was also wondering, you know . . . if my being so overweight was actually causing the milk to be too fatty and not give her enough, essentially.

Alternatively, another participant constructed a counter discourse where, for her, larger breasts were considered harmful for breastfeeding. While stating her larger breasts were ideal as they carried an abundance of milk supply (“There’s so much milk in there”), this participant’s breasts also created challenges for breastfeeding (“[Friends and family] think I will smother the baby”). It was clear that protecting her child from the “threat” of her own nursing body was a priority in her breastfeeding practice: “I’m not going to let the boob smother the baby obviously! If I have to hold the boob up . . . but I ain’t going to let it smother the baby!” After giving birth, another participant positioned her large body as counter to productive breastfeeding, recalling,

I had one nurse try and tell me “Oh, you should be doing cross-body instead of football hold.” I tried cross-body—it didn’t work for me. I’m too big chested; I have to do football hold. I can’t even get around him . . .

Similar to the others, yet another participant described how her body size was impacting breastfeeding goals:

The nursing pillow didn’t fit . . . I had it around me, I had it under me—it just didn’t fit . . . that really kind of freaked me out a bit—it made me very much aware of how much I weigh . . .

Participants’ descriptions of their bodies as they negotiated breastfeeding practice suggest a misalignment between the discourse of the naturalness of breastfeeding and a discourse that constructs breastfeeding as complicated and potentially harmful. Consequently, as each participant experienced challenges with breastfeeding, they referenced a failure of their physical self. Statements made by participants included “I thought [breastfeeding] was all going to be flowers and sunshine . . . but it’s not been that way at all . . . It’s been a gong show!” and “Boy was I in for a shock! . . . I can’t believe [my child] had to spend a week in the hospital because my boobs don’t work. I had no idea, that could even happen . . .”

Furthering this tension was how breastfeeding was represented as something to be surveilled; subsequently, participants both monitored their breastfeeding practice and described their breastfeeding and maternal adequacy in quantifiable ways—weight gain of their babies and breastmilk volume and flow. Health professionals recommended several participants augment their milk production by using domperidone, a drug that increases secretion of prolactin, a hormone involved in making human milk. This health system involvement, which reaffirms there is a problem, and the reliance on health professionals’ expertise further subverted participants’ prenatal construction of breastfeeding as a natural practice. Moreover, the absence of a visible, tangible measure of breastfeeding success added to the mistrust of their bodies and frustration experienced by the participants:

The public health nurse, she was at my house and I was like well . . . can’t I pump this much breastmilk and you guys take a sample of it and tell me if it’s ok and if it has everything he needs and she’s like ‘no there’s no way to test your breastmilk . . .’ And I was like well then how am I supposed to know if it’s working or if . . . my breastmilk is doing him any good whatsoever if no one can actually answer that question. There’s no way to test, there’s no way to know, there’s no way to be sure . . . I sometimes suspect that formula’s the only way he’s getting any nutritional value.

“Red Flag,” and Manifestations of Doubt

Perceived fitness to mother was associated with how participants positioned their physical and social selves as adequate for breastfeeding. One participant repeatedly identified herself as “a scandal,” signified by her older age and having a baby out of wedlock along with living with income constraint. Similarly, another participant noted sarcastically that contemporary parenting discourse does not account for varied social contexts. Commenting on the regular prenatal updates received from a phone app, she stated, “[The app’s] like ‘now’s a good time to start cooking meals in advance and putting them in your freezer’ and I was like—yeah, cause I know where I’m gonna live in two weeks.”

While institutional surveillance and monitoring was a shared experience for all participants, it was particularly amplified for the three identifying as single mothers who all described experiencing judgment about their capabilities of parenting:

I’m a single mom, I’m on welfare, and I’m already seeking help for mental health and emotional health issues. [The health authority] has a lengthy record of my past involving addictions. So you know, they’re just waiting for me to fuck up.

For another participant, proving herself to be a good mother began just after her baby’s delivery when she was visited in the hospital by representatives from community services, recalling, “I hadn’t been a parent . . . for 3 days yet. And [Child Protection Services] were telling me ‘no, no, no you can’t parent’.”

While these participants described how they attempted to follow expert guidance regarding exclusive breastfeeding (“I was never not breastfeeding”), ultimately, the lack of weight gain in their newborns prompted institutional scrutiny and action. The most extreme case resulted in the removal of one newborn from a participant’s care. After her baby was placed in provincial custody, the participant described how she continued to feel negatively characterized and misrepresented, validated by reading verbatim the legal case notes that were written about her. Similarly, another participant described surprise that “she was not making enough breastmilk,” but also that the readmission of her son to the hospital initialized a surveillance process whereby she was accused of child neglect with the threat of child protection involvement.

For another participant who indicated that she no longer wanted to “mother” her child, she resisted the normative maternal identity and constituted herself within a different subjectivity—a biological mother, but not a primary caregiver. These subject positions were not mutually exclusive; however, she continued to experience tension through her interactions with health professionals and those within her social network. Any deviation from the discourse situating mothers as the primary nurturers for their children was experienced by this participant as socially problematic.

Shifting Priorities: Good-Enough Mothering

Participants described a push and pull as they navigated different subjectivities as new mothers. This negotiation was particularly evident when three of the participants experienced unexpected personal health challenges arising shortly after giving birth. Identifying as a “patient” and prioritizing self-care undermined their capacity to fulfill successful breastfeeding practice and primary caregiving responsibilities, thus subverting normative maternal identities. Participants demonstrated their agency by positioning their infant feeding practices within a range of possibilities of mothering; breastfeeding was one option available to them: “I was depressed at first ‘cause I really wanted to breastfeed, but now since [personal health issue] . . . whatever, it can’t happen. [I told myself] You tried your best . . . I’m all right with it now, but . . . I definitely tried.”

Living with limited resources shaped participants’ perspectives of good-enough mothering. Participants’ narratives described the day-to-day “struggle”: “You are doing the best you can to survive.” One participant, raising her baby as a single mother, suggested that the realities of exclusive breastfeeding misaligned with her present situation:

. . . you know, I’m doing this all by myself so . . . instead of sitting down and breastfeeding for four hours, you know, it’s one of those things that’s . . .don’t get me wrong it would be worth it to do it. But where it’s just me here? . . . I don’t think it’s very . . . you know what I mean? Conducive?

Another participant who encountered challenges with breastfeeding and provided both breastmilk and formula to her baby in the first month spoke about breastfeeding within consideration of this context:

. . . it’s not gonna be as healthy for him to feed him formula, and it’s gonna be a lot more expensive and stuff, but I’d rather him get the food that he needs, you know what I mean? And be a happy baby than not right? So . . . when it comes down to it, as long as he’s eating good and everything, I’m ok with it I guess, I mean I kinda gotta be right?

Participants experienced anxiety to breastfeed. They used terms like “stress” and “pressure,” and they expressed feelings of guilt, defeat, and “not doing enough” for the weight and nutrition-related health of their children. Positive relations with health professionals were experienced when participants perceived that the professionals respected and validated their experiences, while acknowledging the participants’ agency and personal autonomy regarding decisions about the care of their babies. Participants expressed their desire for health professionals to show greater empathy for the issues encountered by breastfeeding mothers, rather than taking the normative position of breastfeeding is the way infant feeding “has to be or should be.” For one participant, approval from health professionals about her infant feeding decisions facilitated a positive parenting experience and promoted feelings of maternal adequacy: “I needed validation that it was OK to not [breastfeed] anymore. . .,” she stated,

I kinda feel like I’m defeated or that it’s . . . a lot of pressure to [breastfeed] and then if I can’t . . . you feel like you failed? Right? And that’s what I was saying about the whole entire time is that I felt like I had failed. I felt like I had failed as a mom; I felt like I had failed with breastfeeding . . .

Infant feeding practices thus manifested as a relation of power; participants demonstrated agency by resisting the dominant discourse signifying breastfeeding practice as a maternal good and reshaping breastfeeding practice for their context. In negotiating their infant feeding decisions, participants described the important role that health professionals played; their expertise was valued for supporting them in navigating new parenthood and affirming their experiences as capable mothers and the decisions that they made regarding infant feeding and health-related practices. This was particularly important in the early days and weeks postpartum, which is a critical timeframe for establishing a breastfeeding relationship. Participants would resist support if they felt disrespected and that their situational context was not adequately acknowledged. Recalling health professionals who were not supportive, one participant declared, “Basically now I’m just like, shut up. [laughter] I don’t care . . . cause I don’t anymore. It’s just one of those things . . . just cause it’s not their way, doesn’t mean it’s not . . . the right way.”

Discussion

Using a feminist perspective and Foucauldian concepts, this inquiry reveals the complexity of breastfeeding practice experienced by women living with high body weights and limited resources that affect their food security. While there was diversity in the participants’ experiences, their expectations about, and experience of mothering was a critical position from which participants negotiated their breastfeeding and other health-related practices, it also influenced their interactions with health and social institutions.

Our findings suggest that the participants’ beliefs and values aligned with dominant societal understandings of breastfeeding, maternal excess body weight, and income-related food insecurity. Breastfeeding was represented as a good maternal practice (Marshall et al., 2007) and high body weight was considered a failure of personal responsibility (Gard & Wright, 2005; Greener et al., 2010). Living with material constraint heighted participants’ responsibilities managing food within the household—already a taken-for-granted practice of mothering (DeVault, 1994). After giving birth, participants described the tensions and contradictions throughout this early mothering experience, moving beyond representing breastfeeding as a fundamental health “good” toward a more nuanced negotiation of breastfeeding practice. Participants’ interactions with institutions impacted how they experienced themselves within multiple subjectivities and competing discourses, and where maternal actions were negotiated, and agency was exercised. Foucault’s concepts of the “gaze” as medical and social surveillance, biopower, and governmentality are critical insofar as helping to interpret participants’ beliefs and knowledge pertaining to pregnancy and parenthood, but also by understanding how subjects and subject positions are produced from their exposures.

Perspectives of mothering are ubiquitous and historically shaped, permeating through social and institutional networks. The finding that the good mother discourse played a significant role in participants’ experiences is unsurprising and consistent with work from other scholars; however, this does not reduce its significance to this research study. Foucault’s concept of the subject as produced through regimes of power is particularly useful for the interpretation of our findings, with participants signifying good mothering as a person providing and nurturing her children through a variety of repeated, socially acceptable activities (Ruddick, 2007).

Participants constructed a discourse of an ideal mother body—both in physical and social form. This construction was reinforced through interactions within their social networks and institutions. The surprise shared among participants when experiencing breastfeeding challenges suggests a tension within the normative position of breastfeeding as a “given” or “straightforward” practice. Participants blamed themselves and conceptualized their challenges through their pre-existing discursive constructions of an ideal maternal body that can naturally breastfeed. This is an important finding that merits further exploration for its implications for care and support for breastfeeding mothers. While there is growing evidence documenting the varied breastfeeding challenges experienced among women with higher body weights (Babendure et al., 2015), there is still a lack of evidence about how this knowledge is integrated within daily practices of health professionals (Garner et al., 2014).

Health professionals may also be reifying an ideal, physical maternal body within their practices. Participants described the deployment of medical technologies as a means of correcting nonconforming maternal practices (e.g., domperidone to augment milk supply) and/or institutional surveillance (e.g., weight checks for baby). The tension that emerged between breastfeeding as “natural” but also requiring “surveillance” suggest that when infant feeding practices are disciplined through biomedical interventions, this runs counter to the discourse suggesting that all female bodies “naturally” breastfeed. This tension manifested as frustration experienced by the participants and mistrust of their own bodies and of the health system.

Biomedical discourse played a prominent role in this inquiry exemplifying how breastfeeding, high maternal body weight, and income-related food insecurity produce and reify discursive institutional practices such as monitoring and surveillance and produce the subject positions of (medical) expert and patient (Foucault, 1973). Participants spoke about the habitual monitoring and surveillance that occurred throughout their pregnancy and into the postpartum period, activities that Foucault would term the prenatal and postpartum gaze; a form of biopolitics (governmentality) specifically related to practices and surveillance of the self (Foucault, 1986). This was evident as participants shared their experiences of monitoring and watching their weight and their food practices while under consistent resource constraint. Participants’ practices of the self, signified either as good or “other,” were directly related to their maternal subjectivity.

The deployment of biomedical discourse and its effects were also present within social services. This discourse was used to invalidate one participant’s capabilities of parenting and another participant’s constitution as a “welfare queen” (Cassiman, 2008) and, thus, unfit for parenting. Collectively, participants’ stories form an exemplar case for how biopolitics are deployed by institutions as an apparatus of power (Foucault, 1977). The surveillance experienced by these participants led to absolute or threatened involvement to remove their children from their care. While not all participants described experiencing this higher level of surveillance, it nonetheless illustrates how the good mothering discourse is deployed in practice, with significant implications for women living in challenging social conditions.

To our knowledge, the “invisibility” of breastmilk has not been previously described in relation to mothers’ perceptions of breastfeeding success. Several participants indicated that consuming foods of minimal nutritional quality because of their food insecurity was implicated in reduced breastmilk quality and quantity; moreover, some participants perceived that their high body weight (as a marker of their physical health) was negatively affecting their breastmilk. Participants acknowledged that formula’s visibility and “knowing” formula’s composition made its use more attractive for them.

The concept of “inadequacy” has been previously described referencing women living in social and economic deprivation who face circumstances that may factor into physiological mechanisms to negatively impact breastfeeding practices (Chin & Solomonik, 2009). Where participants represented their breastmilk or their bodies as inadequate, the inadequacy of their social conditions strongly influenced their infant feeding decisions and outcomes. It is well documented that “insufficient breastmilk supply” is a means by which mothers rationalize their transition from full to partial breastfeeding or even discontinue breastfeeding even while this concept is acknowledged as a perception rather than a reality (Meedya et al., 2010). Insufficient breastmilk supply as a rationale for discontinuing breastfeeding is reported among women with high body weights (Kair & Colaizy, 2016; O’Sullivan et al., 2015) and also among mothers identifying as low income (Rozga et al., 2015). Insufficient breastmilk supply implies that the quantity of breastmilk is unsatisfactory to meet the needs of the nursed baby; our findings support that the concept of insufficiency be extended to consider a dimension of breastmilk quality, which for some participants is related to their identities as persons living with food insecurity and high body weight.

Implications

The findings from this study point to the need for better representation of the varied contextual and contradictory realities of infant feeding facing women and their families who live in challenging social situations. An improvement over current health practices would be to consider that the social construction of breastfeeding is implicated in the practice itself, but also in a person’s evolving maternal identity. Being forthright about the diverse challenges experienced by breastfeeding women in pregnancy and lactation resources and programs would be a meaningful contribution by bringing balance to current representations and help build trust with patients and clients. For instance, the knowledge that human milk production may be negatively altered by physiological responses to birth, birth-related interventions, body weight, or other postpartum stresses that affect the health and wellbeing of the mother and her baby (e.g., the stress associated with a lack of financial resources) should be more explicitly described within the context of establishing a successful latch and an early breastfeeding relationship. Likewise, including in breastfeeding resources practical information related to an array of challenges and ways to address these challenges would be beneficial to mothers, infants, and the health system.

While some experiences may be more commonly shared, targeted, supportive strategies may be necessary for breastfeeding women who are also experiencing resource challenges as well as having a high body weight. Detailing breastfeeding position options for an array of breast and body sizes would help ensure that breastfeeding practice can be optimized for women of all body shapes. Those who provide support to this population should consider how a woman’s nutritional health affects perceptions of the quality of her breastmilk supply. Within the you-are-what-you-eat discourse, it is not surprising that some participants from this study openly questioned the quality and nutritional value of their breastmilk within the context of personally experiencing food insecurity and high body weight. The choice to breastfeed or provide a “known nutritional alternative” (infant formula) was rationalized through their perceptions.

There is evidence that momentum is shifting to the consideration of a person-centered focus on breastfeeding. Updated guidelines within North America suggest that language and promotion surrounding breastfeeding should attend to the patient as the central figure in infant feeding decisions and that health professionals have a duty to “. . . validate each woman’s efforts and experience” (American College of Obstetricians and Gynecologists’ Committee on Obstetric Practice, Breastfeeding Expert Work Group, 2016). While some mothers may choose not to exclusively breastfeed for a variety of reasons, all mothers should be well supported by the health system (Critch & Canadian Paediatric Society Nutrition Gastroenterology Committee, 2013). Women can engage in multiple ways of mothering, and this should not hinge solely on their ability to breastfeed their child. This is a particularly important consideration among women who experience resource constraint.

Findings from this study merit further exploration to inform current models of health service and delivery. The tensions experienced by participants negotiating differing or conflicting subjectivities within the context of infant feeding would provide important insight. Further exploration is required related to constructions of an ideal maternal body and how this is related to perceived breastmilk adequacy (both quality and quantity). Studies should continue to examine the implications of punitive surveillance on the breastfeeding practices of low-income mothers (Peckover & Aston, 2018). Finally, it is the much-needed exploration of health professionals’ experiences in supporting breastfeeding women experiencing excess body weight and food insecurity and implications for the practice of person-centered care and support.

Study Limitations

The impact of varied social, cultural, and geographical differences cannot be ascertained for transferability of findings; participants for this inquiry all lived in an urban setting and had access to perinatal services provided by a tertiary-care birthing center—supports that may be limited or absent for women in other geographies. The social and cultural location of study participants may also have factored into the findings. While the recruitment strategy was executed as to maximize the potential for participant diversity, it remained that the majority of participants identified as Caucasian and the study fails to account for experiences across diverse social and cultural groups. Finally, while challenges in participant recruitment limited our sample size, the adequacy of data within this study suggests that these findings offer an important new perspective to the literature. Consistent with feminist post-structural methodology, these findings represent a partial view of experience, and thus, consideration should be made for transferability to other populations. Further studies are recommended to explore other perspectives of breastfeeding practice within food-insecure mothers with high body weights.

Conclusion

The findings from this study contribute an important understanding of how social norms influence daily health-related practices of new mothers, negotiated through discourses of living with high maternal body weight and income-related food insecurity. Breastfeeding was situated as a good maternal practice and the use of an FPS approach enabled a focus on language and the interrogation of normative perspectives of health issues. Providing person-centered care to all breastfeeding mothers requires that health professionals reflect on how maternal subjectivities are shaping, supporting, and undermining their practices.

Supplemental Material

InterviewGuide – Supplemental material for Mothering at the Intersection of Marginality: Exploring Breastfeeding Beliefs and Practices Among Women From Nova Scotia, Canada Who Identify as Overweight, Low Income, and Food Insecure

Supplemental material, InterviewGuide for Mothering at the Intersection of Marginality: Exploring Breastfeeding Beliefs and Practices Among Women From Nova Scotia, Canada Who Identify as Overweight, Low Income, and Food Insecure by S. Meaghan Sim, Sara F. L. Kirk and Megan Aston in Qualitative Health Research

Supplemental Material

Table_1_SupplementaryFile – Supplemental material for Mothering at the Intersection of Marginality: Exploring Breastfeeding Beliefs and Practices Among Women From Nova Scotia, Canada Who Identify as Overweight, Low Income, and Food Insecure

Supplemental material, Table_1_SupplementaryFile for Mothering at the Intersection of Marginality: Exploring Breastfeeding Beliefs and Practices Among Women From Nova Scotia, Canada Who Identify as Overweight, Low Income, and Food Insecure by S. Meaghan Sim, Sara F. L. Kirk and Megan Aston in Qualitative Health Research

Supplemental Material

Table_2_SupplementaryFile – Supplemental material for Mothering at the Intersection of Marginality: Exploring Breastfeeding Beliefs and Practices Among Women From Nova Scotia, Canada Who Identify as Overweight, Low Income, and Food Insecure

Supplemental material, Table_2_SupplementaryFile for Mothering at the Intersection of Marginality: Exploring Breastfeeding Beliefs and Practices Among Women From Nova Scotia, Canada Who Identify as Overweight, Low Income, and Food Insecure by S. Meaghan Sim, Sara F. L. Kirk and Megan Aston in Qualitative Health Research

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: S Meaghan Sim was supported by doctoral research awards from the Nova Scotia Health Research Foundation and the Canadian Institutes of Health Research.

ORCID iD

S. Meaghan Sim

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Supplemental Material for this article is available online at . Please enter the article’s DOI, located at the top right hand corner of this article in the search bar, and click on the file folder icon to view.

Author Biographies

S Meaghan Sim is a CIHR Health System Impact Postdoctoral Fellow focused on health within vulnerable populations. She is co-located between the Nova Scotia Health Authority and Dalhousie University.

Sara F. L. Kirk is a professor of Health Promotion in the Faculty of Health and Scientific Director of the Healthy Populations Institute at Dalhousie University.

Megan Aston is a professor at the School of Nursing, Dalhousie University. She uses feminist poststructuralism to research maternal, child and newborn health in the community and hospital as well as children with intellectual disabilities, their parents and health care professionals.

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