Barriers Affecting Breastfeeding Practices of Refugee Mothers: A Critical Ethnography in Saskatchewan, Canada
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1. Introduction
Refugee mothers are vulnerable to cultural stereotyping and socioeconomic hardships when they migrate to a new country [1]. This vulnerability often has a negative impact on refugee mothers’ breastfeeding practices, related to social, emotional, psychological and physical stressors [2]. Breastfeeding in a new country often places refugee women in an environment where they face contradictions and conflict [2]. Refugee mother and child dyads are especially challenged by food insecurities and the distribution of commercial complementary foods by various service providers and humanitarian agencies [3], which negatively affects the breastfeeding practices of refugee mothers.
Refugee mothers in general are reported to have a lesser duration of breastfeeding due to individual and environmental barriers [4,5], despite healthcare recommendations [6]. Refugee mothers arriving in a new country often present with language difficulties, and they may not have health insurance coverage [1]. In addition, they may lack access to culturally and gender-sensitive healthcare services with breastfeeding support in refugee camps and host countries [1,2,4]. These cumulative obstacles create barriers to the utilization of breastfeeding support services by refugee mothers [1]. The health care system of the host country, hospital policies, postpartum services, and availability of breastfeeding support in the native language also affect the breastfeeding experiences of refugee mothers in a new country [7]. Although the availability of healthcare support towards the breastfeeding of refugee mothers and the baby-friendly status of healthcare settings is reported to increase the initiation and duration of breastfeeding, only 37 health centres/health authorities in Canada are reported to have baby-friendly status [8].
Saskatchewan is one of the rapidly growing Canadian provinces that supports baby-friendly initiatives (BFI) [9]. However, despite this voiced initiative, Saskatchewan has only one healthcare facility with a baby-friendly status [9] and has a limited number of healthcare facilities providing services to refugee mothers with young children. Over the past 15 years, rapid growth in the number of refugee mothers with young children is noted in this province, which indicates an increased need for breastfeeding support for refugee mothers and suggests the need for increased inclusive BFI in all healthcare settings [10,11,12].
Previous studies undertaken with refugee mothers in Canada provide insight into challenges encountered by refugee mothers in general, including personal beliefs [13,14,15], financial hardships [16,17], inadequate support from healthcare providers [18], challenges in accessing healthcare services [19] and inconsistencies in provincial breastfeeding guidelines and policies [20]. Despite the initiation of the “Interim Federal Health Programme (IFHP)” and other provincial health insurance plans that cover basic and supplemental healthcare costs for refugees, it is essential to understand the appropriateness, relevance, and quality of the offered services to breastfeeding refugee mothers in Canada. This is especially relevant to provinces such as Saskatchewan which have a noticeable influx of refugees. To promote, protect and support the breastfeeding practices of refugee mothers in Saskatchewan and minimize potential risks towards the health of young refugee children, it is imperative to have an in-depth understanding of factors that facilitate or impede breastfeeding practices of refugee women accessing and utilizing healthcare services in Saskatchewan.
Previously undertaken studies [13,14,15,16,17,18,19,20] do not uncover barriers surrounding breastfeeding practices of refugee mothers accessing and utilizing Canadian healthcare settings. There are significant gaps in the knowledge and a lack of empirical studies that focus on the breastfeeding practices of refugee mothers accessing and utilizing healthcare services in Saskatchewan, Canada. Saskatchewan’s noticeable increase in the population of refugees with young children, its limited availability of healthcare settings with baby-friendly status, potential risks towards the health of young refugee children after breastfeeding discontinuation, and existing gaps in the knowledge, all suggest a pressing need to explore challenges to the breastfeeding practices of refugee mothers. There is a defined need for empirical research on the barriers surrounding refugee breastfeeding mothers’ access and utilization of healthcare services in Saskatchewan, as well as an exploration of recommendations from refugee mothers regarding their needs for breastfeeding support programs and interventions in the healthcare settings of Saskatchewan. This study aimed to explore the barriers that impede the breastfeeding practices of refugee mothers accessing and utilizing healthcare services in Saskatchewan, Canada.
2. Materials and Methods
A critical ethnographic study design was employed to examine the barriers that directly and indirectly affect the breastfeeding practices of refugee mothers accessing and utilizing healthcare services in Saskatchewan. Critical ethnography is identified as an appropriate design to undertake this research because this design provides an opportunity to critically examine the issues surrounding the lives of people experiencing struggles and vulnerability [21,22]. Moreover, this design provides an opportunity to examine the experiences of a potentially vulnerable group and analyse the association of those experiences (multiple realities) with power and truth [23]. Hence, critical ethnography helps a researcher to gain insight into the range of factors in social structures that shape the experiences of oppressed groups [21], in this case, refugee mothers of young children.
This study was undertaken in Saskatchewan, Canada. Ethical approval was sought from the University of Regina Ethics Review Board before the commencement of the data collection (number 2020-104). Data were collected from the year 2020 to 2022 using multiple methods, including in-depth interviews with refugee mothers with young children aged 1 day to 24 months, field observations of community-based services/facilities available to refugees in Saskatchewan, and a review of media communications. In view of the emancipatory agenda of critical ethnography, the use of multiple methods of data collection helped in uncovering the truth from a deeper level, in triangulating data, and in examining the range of factors that affect the breastfeeding experiences of refugee mothers.
In-depth interviews were conducted with refugee mothers having young children aged 1 day to 24 months until saturation (richness) in data was achieved. Altogether, 27 interviews were undertaken. Participants were recruited using a purposive and snowball sampling method from different cities of Saskatchewan, including Regina, Saskatoon, Prince Albert, Swift Current and Moose Jaw. Refugee mothers were recruited with the help of the refugee settlement organizations offering services to the refugee population in Saskatchewan. A semi-structured interview guide was utilized to undertake interviews of 40–60 min with refugee mothers. The questions intended to explore the breastfeeding experiences of refugee mothers and key barriers that negatively affect their breastfeeding practices. Due to the COVID-19 pandemic and related restrictions, all interviews were conducted via Zoom. Interviews were conducted in refugee mothers’ preferred languages (mainly English and Arabic). Of 27 mothers, 24 refugee mothers preferred to be interviewed in Arabic and the rest of the mothers were interviewed in English. After seeking informed consent, data were collected by the principal investigator and a research assistant fluent in English and Arabic. All interviews were audio recorded. Interviews conducted in Arabic were transcribed and translated into English by the research assistant. An audit trail of the interviews conducted in Arabic was undertaken by a language expert to check the accuracy of the translation. Field notes were maintained by the researcher during data collection.
Field observations were conducted by the researcher to observe healthcare and environmental barriers experienced by refugee mothers in Saskatchewan. The researcher made observations on services available to refugee mothers, including social support services for refugee families, availability of interpretation services, privacy to breastfeed in public, helpline services in different languages, cost of transportation services to healthcare, and hospital practices during the pandemic. Field observations assisted in identifying a range of accessibility challenges encountered by breastfeeding refugee mothers with young children.
To supplement the field observations, a review of media communications focusing on breastfeeding services and resources for refugee mothers was undertaken. The researcher reviewed websites maintained by the health authorities, refugee settlement services, public libraries and social services actively working in Saskatchewan. Altogether, four online reports and six websites maintained by governmental and non-governmental agencies in Saskatchewan were reviewed. Field notes were maintained during the document review.
The data were analysed iteratively and inductively. Data gathered through multiple methods, including in-depth interviews, field notes, media communications, and field observations were analysed manually by the researcher. Multiple steps were followed to analyse data. Firstly, we developed codes representing breastfeeding challenges encountered by refugee mothers. Approximately 60 codes were derived from the data gathered through in-depth interviews with participants and field notes gathered during the review of media communications/reports and field observations. Secondly, codes were classified (into categories) representing the root cause of breastfeeding challenges (maternal factors or external factors). As a next step, four broad themes (i.e., psychosocial barriers, healthcare barriers, environmental barriers, and maternal–child health-related barriers) were derived to present the range of barriers that directly and indirectly affect the breastfeeding practices of refugee mothers in Saskatchewan.
The trustworthiness of the data was assured by undertaking member checks with the study participants. Refugee mothers were contacted to seek verification of the interpretations from the data gathered through multiple sources. Triangulation of data was another strategy that facilitated the researcher to gain in-depth insight into the barriers negatively affecting the breastfeeding practices of refugee mothers in Saskatchewan. Throughout the process of data analysis and presentation, the anonymity and confidentiality of the study participants were assured by using identification numbers.
4. Discussion
Refugee women often deal with multiple stresses linked to both motherhood and displacement [24]. Promoting, protecting and supporting the breastfeeding practices of refugee mothers is vital to minimizing potential risks regarding the health of young refugee children. This study identified the role of psychosocial barriers, healthcare barriers, environmental barriers, and maternal and child health-related barriers in impeding the breastfeeding practices of refugee mothers accessing and utilizing healthcare services in Saskatchewan. This study provided preliminary data that will be useful in informing healthcare providers regarding the breastfeeding practices of refugee mothers in Saskatchewan, Canada.
This study underscores that psychosocial barriers and lack of social support in a host country are the key barriers to breastfeeding practices of refugee mothers. Refugee mothers, who experience family separation and forced migration from one country to another, are at risk of experiencing reduced physical, mental and emotional wellbeing, especially during the perinatal phase of their lives [1,25]. Refugee mothers require support to maintain their traditional breastfeeding practices as these practices promote infant health, growth and development. This has been indicated by studies which indicate that breastfed infants are less susceptible to wasting and low weights [4] and are more resistant to infection [26] during displacement and resettlement in a new country. Feeding breastmilk to refugee children who are in high stress living situations reduces the risk of mortality and supports healthy growth and development [27].
Healthcare barriers form another set of challenges that impede the breastfeeding practices of refugee mothers and which negatively affects the health of young refugee children due to the use of a formula that holds more risks than benefits. These healthcare barriers suggest the need for adequate breastfeeding support from healthcare professionals, culturally sensitive care (interpretation services, cultural food in hospitals and healthcare free from racism), and implementation of baby-friendly initiatives in healthcare settings in Saskatchewan. Five challenges associated with migration that affect the ability of new mothers to breastfeed include “language barriers, racism, discrimination, poverty and separation from culture and family, and separation from their culture” [28] (p. 51). Many refugee mothers who have been torn from their home countries due to war and conflict experience anxiety and insecurity that interferes with lactation [29]. To improve the accessibility of breastfeeding services to refugee mothers, this study suggests the importance of offering prenatal and postnatal breastfeeding counselling services and educational materials to refugee mothers in multiple languages. As language barriers and the non-availability of interpretation services in healthcare settings are common barriers for refugees, which negatively affect their accessibility to healthcare [30], the use of paid professional interpreters in the community and health is vital in supporting and empowering new refugee mothers [31]. The International Society for Social Pediatrics and Child Health (ISSOP) Migration Working Group stressed that unmet prenatal, perinatal and postnatal needs, often related to language barriers, may lead to increased mother and infant morbidity and mortality [32]. Healthcare services offered in their language have been shown to expedite healthcare access by refugee women [28]. A study conducted with refugee women in Finland indicated that interpreters reduce obstacles to quality care throughout all three of the following phases of maternity care: deciding to seek care, identifying and reaching the health facility, and receiving adequate and appropriate care [31].
Adequate nutrient intake is crucial for maintaining maternal energy balance, and suboptimal nutrition can affect breast physiology and milk production [33]. The findings suggest that, for refugee mothers, who are already experiencing stress due to relocation, the absence of culturally approved foods in hospitals provides yet another impediment to the establishment of successful breastfeeding. This study further suggests the negative effects of racism on the breastfeeding practices of refugee women. The recent growth of the population of refugee mothers in Saskatchewan appears to be associated with the unintended cultural and institutional or structural displays of racism that hinder successful breastfeeding. Racism is thought to negatively affect health through a variety of complicated processes, including the harmful physiological reactions to stress that can occur through both individual and systemic pathways [34]. Women of colour are reported to have lower rates of breastfeeding continuation when compared with white women [35], this suggests the crucial need to overcome racism and address breastfeeding inequities in the healthcare system. Cultural racism, or the influence of negative stereotypes upon care providers, can be reduced through education programs for the healthcare providers that describe the cultural and psychosocial needs of refugee mothers with young children.
This study further highlighted the negative effects of environmental factors on the breastfeeding practices of refugee mothers, mainly lack of transportation, cold weather conditions, lack of child daycare facilities, lack of privacy to breastfeed, and the COVID-19 pandemic. The resettlement context is reported to influence refugee families’ access to healthcare services in the host countries [30]. Studies undertaken with the vulnerable and marginalized group of mothers highlight a variety of barriers that affect their breastfeeding practices. These barriers include lack of transportation [36], non-availability of affordable child daycare facilities in communities [37], weather conditions [38], lack of privacy in public spaces [39], and the COVID-19 pandemic [40,41]. Considering the range of environmental factors negatively affecting the breastfeeding practices of refugee mothers in Saskatchewan, this study suggests that refugee mothers must be offered community-based follow-up care and online breastfeeding counselling services in multiple languages. Moreover, refugee mothers must be offered culturally sensitive accommodations, support and privacy to breastfeed in healthcare settings, public parks, airports, businesses and public transportation. These services require interdisciplinary collaboration between the government, healthcare system, social services and refugee settlement agencies.
Maternal and child health status is another important factor that positively or negatively affects the breastfeeding practices of refugee mothers. The findings suggest that refugee mothers who often experience trauma due to disasters and subsequent migration face additional breastfeeding challenges related to their own or their child’s health. In general, breastfeeding challenges, such as perceived inadequate milk supply and difficulties with breastfeeding techniques, are significant contributors to breastfeeding cessation [42]. Therefore, promoting maternity care practices that support breastfeeding, such as ensuring skin-to-skin contact after birth, encouraging early initiation, and supporting cue-based feeding, is essential [43]. The method of childbirth, whether vaginal or caesarean, also affects breastfeeding initiation, where vaginal birth allows for earlier skin-to-skin contact, facilitating breastfeeding. Physical recovery and emotional adjustments during the postpartum period are critical for refugee mothers’ comfort and ability to breastfeed successfully. Positive breastfeeding experiences are associated with mothers perceiving more time for motherhood, linking to better mental health outcomes. Conversely, negative experiences arise from factors like separation from newborns, breastfeeding struggles, and perceived lack of support, leading to worse mental health outcomes [41,44]. Infants’ health, in addition to maternity, can also influence breastfeeding. Physical challenges like difficulty latching or weak sucking reflex [45] and medical conditions such as colic, tongue tie, or cleft palate [46,47] can impact effective breastfeeding, affecting latch and milk extraction. The findings suggest the importance of offering need-based healthcare support, culturally sensitive care and breastfeeding counselling services to refugee mothers in their native language. Refugee mothers who are at risk of experiencing post-traumatic stress disorder must be involved as partners in designing breastfeeding programs and services. Furthermore, healthcare professionals must be trained to conduct safety assessments, comprehend non-verbal cues, and offer psychosocial interventions to safeguard the health and well-being of breastfeeding refugee mothers [48].
This research identified gaps existing in the breastfeeding services and programs presently offered to refugee mothers in Saskatchewan. The knowledge from this project will assist in ascertaining the need for the development of baby-friendly support measures that promote quality care for breastfeeding refugee mothers in Saskatchewan. Recommendations from this study can guide the development of comprehensive, need-based, culturally sensitive and context-specific breastfeeding support interventions for refugee mothers with young children. Stakeholders from health, policy and social services in Saskatchewan can utilize the recommendations from this study in designing and developing baby-friendly programs and guidelines that can promote, protect and support the breastfeeding practices of refugee mothers. Future studies in this area must target the development and testing of community-based culturally sensitive breastfeeding support interventions for refugee mothers in collaboration with patient partners, health authorities, social institutions, governmental agencies and refugee settlement agencies.
5. Conclusions
Refugee mothers with young children are at risk of discontinuing their breastfeeding practices. This critical ethnographic study, undertaken with refugee mothers, identified that psychosocial barriers, healthcare barriers, environmental barriers, and maternal and child health-related barriers impede the breastfeeding practices of refugee mothers accessing and utilizing healthcare services in Saskatchewan, Canada. The findings suggest that these barriers lead to physiological challenges, mental health issues and trauma, which negatively affect the breastfeeding practices of refugee mothers. Breastfeeding practices of refugee mothers can be promoted through healthcare support, culturally appropriate services, interpretation services in healthcare settings, implementation of baby-friendly initiatives, hospital and community-based breastfeeding campaigns, and follow-up services. Collaborative efforts by healthcare settings, healthcare providers, policymakers, public health agencies, community-based service providers, and the provincial and federal governments are vital for the promotion, protection, and support of the breastfeeding practices of refugee mothers. Future research must involve patient partners, health authorities, social institutions, governmental agencies and refugee settlement agencies in the co-development of baby-friendly initiatives and breastfeeding support interventions that can promote, protect and support the breastfeeding practices of refugee mothers in Saskatchewan, Canada.
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