Breastfeeding and Perinatal Mental Health: Challenges in South Asian Communities

Dr Marianne Trent (: 00:00

Have you ever considered what additional challenges during breastfeeding and the perinatal period might crop up for South Asian women? In this episode, Zaynab Khan and I discuss the social, cultural and healthcare barriers these women face and discuss how we can provide better support for them and their families. Hope you find this so useful. Hi, welcome along. I am Dr. Marianne and is lovely to have you here. If you haven't already caught the previous episode I did with Zaynab where we were looking more broadly at some of the additional mental and physical health factors that might be around for people with South Asian heritage, please do check that episode out as well or I will link it for you at the end of this episode too. I hope you will find this episode to be really illuminating and if you do enjoy it, please do rate and review if listening on Apple Podcasts, if you are on Spotify, you can rate it.

(: 00:58

Please do drop me a comment, drop me a like, share it with your friends, subscribe to the channel. It's the kindest thing you can do for any podcaster and it's entirely free what is not to like there. Let's dive in and I'll look forward to catching up with you on the other side. Hi, just want to welcome our guests for today, Zaynab Khan. Hi Zaynab, welcome back. Hi, welcome. Thank you. Thanks for being here. Obviously we were in the same outfits, so we've done it on the same day, but we figured that it was worth having a separate conversation about breastfeeding and how to kind of understand that within a South Asian context and that's because you have done research into this area of your undergrad psychology degree, haven't you?

Zaynab Khan (: 01:44

Yes, so my undergrad dissertation was essentially an acceptability study on a breastfeeding workbook that was used. It was off the back of research done by my supervisor into the disparity between women of a high BMI, not reaching their breastfeeding goals despite obviously World Health Organisation recommendations and such. Yeah, so it was like an intervention workbook that we were just trying to get an acceptability study done for however, I decided to branch off and specifically look at it from a South Asian perspective and get the acceptability from South Asian women in particular. Main reason for that was I know from my own family history and cultural knowledge that for us breastfeeding is such a golden standard. It's like the golden liquid, it's so widely spoken about and within my own family breastfeeding is really, really highly encouraged. So yeah, I just thought it would be interesting to see, well, how would it be best to attract their attention and support them psychologically? So yeah, I recruited through online methods. It was mainly through Instagram call outs with a family friend that runs a baby class in Leicester. Yeah, so I sent them the workbook and they were being interviewed about their thoughts on how they think that would've helped them through their own experiences and there's a lot that came from it That I think is what really opened my tunnel into now really wanting to pursue research into psychologically appropriate care for South Asia women.

Dr Marianne Trent (: 03:19

Amazing. I dunno if you've stumbled across Professor Amy Brown who I interviewed for the podcast before. She does lots and lots of brilliant research into breastfeeding and the power of human milk and just feeding practises generally. But she's well worth looking out for to see if she's kind of branched in South Asian stuff as well. But so an acceptability study, that's where we're kind of checking that people like what we're about to launch into the world, is it that it's doing what we hope it will do for different populations?

Zaynab Khan (: 03:51

Yeah, exactly that. So it was literally just to get their thoughts on whether they think it's even worth doing. Do women, I mean for me specifically, I want to know do the South Asian women feel like this workbook is necessary with their own peers appreciate a workbook to support them reaching their breastfeeding goals. I think a lot of the original research into why women don't a women of a high BMI don't reach their breastfeeding goals does come down to mind over matter, not being stigmatised or not feeling competent enough. So I think that was the main push behind needing such a workbook, but actually my interviews almost went very south away from the workbook and so much was brought up with regards to culturally the sort of difficulties that women have regardless of their BMI that South Asian women have when it comes to breastfeeding and actually reaching their breastfeeding goals and even something as simple as clothing.

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So obviously for South Asians, traditional wear can be quite heavy, it can be quite complex and very much not the most breastfeeding friendly outfits and I think almost the narrative of you need to attend these events and you need to wear this sort of attire really puts a lot of women off breastfeeding or they give up early because they have so many of these weddings and events to go to that they tend to bottle feeding even if that's not internally what they want to do or even at family functions if it's not appropriate to breastfeeding in front of male counterparts and things like that. Very much discouraged within our culture of breastfeeding publicly. There really needs to be more to highlight those psychological thought process behind engaging in breastfeeding, especially when it comes to I guess the public breastfeeding whilst the workbook that we showed had a whole section on it, almost the narrative behind the actual workbook when it came to public breastfeeding was not so much assimilated to why women of South Asian descent don't engage in public breastfeeding.

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I think for them it came down to a lot of cultural stigma, also stigma around doing it in front of males and it has to be done hidden and I think, yeah, it was interesting to hear from their perspective of things they wish they had received when it came to their own experiences, especially when it came to things associated with their weight being told they're not good enough by family or being told that because they're overweight, their breast milk's not good enough. I mean that's quite similar to what the general narrative is for white Caucasian women as well from the research, but I think it was more deep rooted for South Asians in regards to their culture in particular, which I think was different.

Dr Marianne Trent (: 06:14

Yeah, so interesting. And I guess there's not necessarily a biological reason why somebody with a higher BMI can't produce breast milk and I think certainly Professor Amy Brown's research seems to suggest that it's only 2% of women who can't produce enough milk to sustain their own child. That's what the evidence tells us. But thinking about my experiences of having been a breastfeeding mother to both of my children, certainly in the early days when you're establishing feeding and when they are cluster feeding, which is really, really exhausting for mom actually because you're getting almost, it feels like constant feeding that is involving a lot of either top off time or clever one up, one down outfit choices and cultural dress may not always make that possible, especially when out and about and it is really challenging establishing breastfeeding, especially if you're being undermined by people around you.

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It's really, really difficult. You need somebody who you don't always need somebody who gets why it's important to you, but it sure does help if someone is willing to bring you a pint of water as soon as you sit down to feed because if someone is trying to undermine you and constantly saying, oh, perhaps they'd sleep better with formula, or perhaps I would actually really like to feed them, I'm going to feed them a bosel that can affect a mother's mental health. It can affect how she's able to produce milk in future. It's a really big deal.

Zaynab Khan (: 07:52

Yeah, exactly. And I think speaking about South Asia in particular, I know that there was a huge brand that went into India years and years and years ago and introduced formula milk which was incentivized by free formula milk and things like that, and it really, really perpetuate this cycle that's really gone down tradition to tradition because it was linked so heavily, their advertising was linked so heavily to, well, if you use formula, you can do the housework, you can get on with the chores, you can look after your other children, you can pass the baby from family member to family member. It was really tying into certain cultural niches that it has. I know it sustained such a long standing tradition now within cultures that I actually wasn't aware of until I did this research just given that within my own family circle, they've all, everyone's been breastfed, it's very much spoken about, but after doing meditation it really highlights to me actually almost the narrative slightly switched within South Asian.

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A lot of actually, why don't we try formula? Because it does mean that you can, because we're such family oriented people, we have such large families, typically it has been perpetuated a lot, but actually if you do use formula you can just hand the baby off to grandma or to aunties and uncles while you get on with the housework. And I think when it comes to then trying to implement psychological interventions or workbooks or anything that can sort of change the narrative around your breastfeeding behaviours and your approach to breastfeeding, if healthcare providers have that knowledge in mind or they just kind of do the almost preparatory work of what is going on for that coach in particular first before we create any sort of intervention, I think they'll have a lot more efficacy in how they work. I think again, it also ties in with not necessarily all healthcare providers. You do get obviously some very good ones, but I think the research that I've looked into anyway, there is a huge disparity between the general perinatal support, whether that's psychological or practical medical help that South Asian women get in comparison to their white Caucasian counterparts. So I think if systemically you've got healthcare providers that don't actually want to do the groundwork of understanding that culture's issues and problems, you're never going to bridge the gap and increase those breastfeeding rates or increase any of the positive babies. That should happen postnatally or even perinatally as well,

Dr Marianne Trent (: 10:15

And whoever I'm supporting as a new mom, I'll always think actually we don't necessarily need them to come around and feed the baby, but if they're coming around, perhaps they could clean the bathroom whilst they're using it, perhaps they could do the cleaning. Would that fly as an intervention for South Asian cultures or would that be frowned upon if I asked my auntie to clean my bathroom when she came around? Yeah, traditionally very frowned upon.

Zaynab Khan (: 10:44

I think it's almost women to be as to held to such a high standard which kind of works in a positive and negative light in some ways I think it's quite a common misconception that obviously women in my culture, for example, are quite oppressed or they're not seen as valuable individuals. But I mean coming from a religious point of view, for me religiously women and within my family, women are held to such a high standard in terms of they are the most valuable members of the community because of how much they have to enjoy, whether it's childbirth and being a parent and so on, so forth. But I think sometimes that can be taken the wrong way where it's because so much is expected of them, that's when the psychological impacts of just certain things like traumatic births, which statistically South Asians have a very high experience of traumatic birth.

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I think it was Irwin Mitchell that did the first ever South Asian perinatal conference recently, and I was reading the report of that and it was all about traumatic births and how statistics aren't being published about the high numbers of traumatic births experienced by South Asians. But if people, and not just healthcare providers, but even family members and friends within the community aren't aware of the impact of even just a normal birth let electro birth, they're so overlooked then that they're just expected to do a lot of the housework and things. So I think a lot of it is there just has to be balanced. I think it's quite common within western culture to almost discredit cultural practises where they encourage these very traditional gender roles or they see it as oppressive and the woman has to be submissive and it's not a good thing.

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I think it ties back to what I've said in the previous episode with you where you have to see it from a culturally appropriate point of view where for us, it's not a bad thing to be a domesticated person or domesticated woman. It's not a bad thing to be the one doing the cleaning, but there also has to be a level of support from other people. So yeah, I mean if it was encouraged that when someone's a new mom, let's help out a little bit more with the housework, that would be great. But I think introducing that within the culture isn't as easy as just saying, well, why don't you ask your auntie next time to come and when she comes over to the cleaning, that's the big difference. Okay.

Dr Marianne Trent (: 12:50

I really liked what you said in the previous episode about the parallels between the World Health Organisation take on breastfeeding and the Quran. Could you tell us a bit more about that?

Zaynab Khan (: 13:00

Yeah, so essentially word for word what you see in the WHO is written a word for word in regards to how many months they recommend breastfeeding. The benefits of breastfeeding, it's literally written word for word in the grant as it is on the WHA website as well. For me, that was highlighted by, I knew that anyway going into this research, but I did notice across the interviews that I did, a lot of them did bring up, they just happened to all be Muslim that I spoke to just by chance, and they all in the way, they were talking about their experiences with perinatal mental health and things like that. They all brought in a religious influence and maybe the comfort they found in prayer or turning to religious leaders and things like that and where they were getting their source of information. And for me, that highlights almost a need for healthcare providers and services to almost bring religion into it where it's appropriate.

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I think again, just in the world we live in, they're always seen as quite taboo topics or you don't bring religion into things or you don't. I think for a lot of these services, especially ones that aren't educated in England or in western cultures or that haven't ever engaged with any education providers at all, if they've migrated from abroad or anything like that for them, they might turn to religious books for their almost education, and I think if there was some knowledge of that from psychological providers, service providers, I think it's not necessarily a bad thing. I think you'd get a lot more reach and a lot more response. Actually, it was very interesting, to be honest,

Dr Marianne Trent (: 14:31

Even just to know to ask the question, is there anything in your faith or your culture or your cultural and religious books that talks about this that might be explaining some of what we're seeing right now, but I seem to remember working with women in the past who really, they recognised that they weren't ready to stop breastfeeding their child and that the baby or the child wasn't ready to stop. But I seem to remember there was some understanding that it was to stop by two years of age. Does that ring a bell for you, Zab?

Zaynab Khan (: 15:05

Yeah, I think the actual, I should really know this off by heart given that I did research into it, but the WHO recommendation, I know that it's exclusive breastfeeding up to six months and then it's supposed to be introduced alongside obviously solids up to two years. So yeah, you are right in saying that.

Dr Marianne Trent (: 15:23

Yeah, but it's, I guess speaking as a mother who did feed both of our children past two years, one was 25 months and one, I had to put a line under it at two years and 10 months. It's kind of at least two years is how I remember the guidance. But that is, I think in certain South Asian cultures it's seen as you mustn't go beyond that it becomes inappropriate or not. But of course what we know the woman who has breastfed is that it's a very individual relationship between you and that child and trying to stop for an external reason rather than a reason that is about you or about that baby choosing to make that stop. So it said there's only two times where you should stop breastfeeding and that's if it doesn't work for you or it doesn't work for baby. But of course having separate guidance around do not continue beyond two years can add lots of elements of guilt, shame and regret and blame and very difficult kind of mental processes there.

Zaynab Khan (: 16:36

Yeah, you're absolutely right. I mean, going back to religious scriptures, it mirrors, it's only a guidance. It's not that you have to stop at two years, but I think culturally a lot of it comes into, I think the intervention that we were looking at there was so much talk about your body, get your breasts out, explore and things like that, and I think one thing that I discussed a lot with the interviews was it's not culturally appropriate to get your breasts out. Exposing body parts is not a thing that we do. Even talking about it within the work with your husband, not also very much encouraged the exploratory side of things of what positions like for you and so on and so forth. Just even something as small as that wasn't very much encouraged because of cultural shame and stigma almost I guess you could call it.

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I think again, I don't think it necessarily should be seen as a bad thing. I just think, again, it's just a cultural preference that we, especially if you come from a Muslim background or typically any religious background within in South Asia, it's that you maintain your modesty and things like that, especially when it comes to your male counterparts or family members or friends. And I think when it comes to obviously going past certain ages, you're right, it does come down to I guess the stigma around, oh, that's a bit inappropriate to look at for whatever reason. I dunno where that ideas even come from, but just I think from the research and healthcare provider point of view, it shouldn't be about questioning where has that come from, more so it's there, it's not going to disappear because a lot of these cultural issues or cultural beliefs they stem from generations ago, it's not something you can change overnight. You can't tackle almost where it's come from. I think that's a lot of the focus when it comes to research is, well, where's this shame coming from? Let's tackle the where I think it needs to just be that it's there anyway, assume it's there and deal with it in that way instead, I think almost giving them just an alternative point of view. A lot of South Asian women stopping exactly two years because of that shame that comes after it almost.

Dr Marianne Trent (: 18:39

Yeah, and I think I know even myself as I was talking just then about how long I'd fed my children for, I had this kind of internal critic like, oh, should you be saying this? Should you be publicly telling people that you'd fed for this length of time? And will people think that you are judging them or s slighting them if they didn't feed for that long? It's really hard, but I'm proud to have fed my children. It was not easy. It was incredibly difficult. Both of them had tongue ties as well, that having a child is not easy and for me, that was just something that I was adamant that I was going to make work and thankfully I wasn't one of the 2% of women that couldn't produce enough milk. There are medical reasons why some people can't do that and there's sometimes personal preference reasons and when it comes to trauma and abuse, obviously there's this absolutely complicates whether someone feels they want to or can breastfeed, but I guess it's what we said before in the first episode.

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If you can see, you can be it. If you've heard Dr. Marianne Trent talking about having breastfed her children beyond two years, maybe that thing makes you think, well, I can work. I can go back to work. I went back to work with both babies a year of age and I expressed, I think this is just we need to be getting better at asking people for their story, for what matters to them, for what external and internal factors might be perpetuating some of these difficulties or these struggles, these challenges. We should be empowering people ourselves, people in our team, people above us, people below us to have these conversations, and I guess it's that it's really difficult, especially as a white British woman, I don't want to get things wrong. I don't want to be making some horrendous cultural gaps, but I think it's entering into this with compassion and good reasons at heart and knowing that it's better to try and ask questions about things that are important. Tot thumb, someone, if you don't understand, you don't know, we cannot be an expert in everything. Podcasts like this help to illuminate areas that we might not even have considered before, but really the person themselves is always going to be the experts on themselves, aren't they?

Zaynab Khan (: 21:08

Yes. I think that literally sums up perfectly. I think it is the big thing that I'm so interested in is I think where it's almost going wrong is at the baseline. I think especially for South Asian women, given that culture, they can be quite stereotypically seen as submissive characters or they don't get their voices heard. I think that's where as a researcher or as a healthcare provider, a clinical psychologist, you really have to be the one that does empower them to speak, and I think it goes down to being exploratory and just curious. I think at the start of meeting a client, if you're asking them almost give me everything about your life story so I can understand would do us a lot more good than it does harm than if we were to ask something and maybe trot on the wrong foot slightly and get something wrong that we don't understand.

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I think that's better to do almost than if you just don't ask and you just assume that they fit to same narrative that we've seen for countless years. I think especially when it comes to perinatal mental health. I think going forward for South Asians, my biggest thing is I want to be the representation for, as a clinician or as a researcher, to almost be the bridging gap between, I think the big thing that we spoke about even in the previous episode is just representation. If you can have some representation somewhere in a service that understands or that can just show that I think like what you said before with, if you can see it, you can believe it. If you can see yourself almost a representation of yourself within your healthcare provisions, you're more likely to want to engage and you're more likely to believe what's being said than if it's someone that doesn't emulate the same beliefs or even look the same as you.

Dr Marianne Trent (: 22:50

Thank you so much. Please could you let us know where people can connect with you and learn more about your research?

Zaynab Khan (: 22:57

I would probably say LinkedIn is the best place to go for that. It's just by Nancy and you'll find me.

Dr Marianne Trent (: 23:03

Thank you so much for helping illuminate our listeners and our watches about this really important issue. Thanks for your time. Thank you so much. However, we, it's been really, really, really good to speak on the podcast today. Oh, thank you. Thank you so much once again to Zaynab for her time in speaking with me, what has this brought up for you? Please do come and let me know on my social media where I am, Dr. Marianne Trent, everywhere. Come and let me know what you think and watch Marianne's motivation and mindset videos, which you can do totally for free by joining my free Facebook group, the Aspiring Psychologist Community with Dr. Marianne Trent. If it's your time and you're ready for the next step, please do consider the Aspiring Psychologist membership, which you can join for just £30 a month with no minimum term, but if you did want to join for a longer period of time, you can get some free one-to-one time with me by signing up for six months or for nine months in one go. There's more details on my website. Please do also check out the Aspiring Psychologist Collective book and the Clinical Psychologist collective book too. If you've got any future episode ideas, please do get in touch and let me know. Thank you so much for being part of my world. If you're looking to become a psychologist,

Jingle Guy (: 24:26

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