Earlier this year I had the opportunity to speak at the Breastfeeding and Feminism International Conference in Chapel Hill, NC. The conference is devoted to highlighting breastfeeding-related research, practice, advocacy, and policy. The meeting theme for 2015 was “Breastfeeding, Social Justice, and Equity: Reflecting, Reclaiming, and Re-visioning,” in celebration of the meeting’s tenth anniversary. I presented my research on maternal-child health disparities in Native Hawaiian and Pacific Islander populations in Hawai’i. What follows are some highlights from this presentation.
Most of us here on the mainland USA don’t give much thought to Hawai’i, except for possibly in our dreams: a dream vacation, a dream honeymoon, a dream life ….
Hawai’i is consistently ranked as the healthiest and happiest state in the nation. Indeed for most population health indicators, Hawai’i comes out ahead of other states. However, this portrait of good health looks different when population data are broken down by socioeconomic indicators, like race/ethnicity, age, or household income. More to the point, Hawai’i may be the “healthiest” and “happiest” state, but only for the privileged majority.
Native Hawaiian and Pacific Islander (NHPI) groups are smaller in number but carry a disproportionate burden of disease in the state of Hawai’i, including significantly higher rates of obesity (among adults and children), type 2 diabetes, and infant mortality. People within NHPI groups report the highest rates of poverty. Obesity, substance use, intimate partner violence, and mood disorders in the perinatal period are also higher among NHPI mothers. While breastfeeding initiation is very high, rates of exclusive breastfeeding from birth to six months and duration of any breastfeeding drop off more quickly among NHPI mothers.
In the summer of 2012 I returned to Hawai’i, which was once my home, to explore how social inequalities translated into infant and young child feeding practices within NHPI families. I had a lot of questions: How were infants being fed in the first six months of life? What were the reasons behind their infant feeding choices? If mothers chose to breastfeed, what was their experience like? When did they start to introduce weaning foods? What kinds of foods did their toddlers and pre-schoolers eat? Who fed the children? Who made decisions about how to feed the children? Where did they get food for their family? What kinds of foods did they have access to? What did they think were the best quality foods to feed their children, and were they able to feed their children these foods?
I spent six weeks in Honolulu and Hilo with families who were either staying in an emergency shelter or living in full-time transitional housing. In addition to participant observation, I formally interviewed parents and other caregivers (n=41), usually grandparents, who had infants and young children in their care. I also spoke with health care providers, community health workers, and shelter staff.
This project was exploratory by design. Although I have worked on issues related to NHPI health for over 15 years, I wasn’t sure exactly what I would learn, and no one (to my knowledge) had examined these issues among homeless families. I did have some expectations that caregivers would share interesting stories about cultural practices surrounding infant and young child feeding. I hoped to gain a better understanding of how parents worked to meet their children’s needs in culturally meaningful ways.
Soon after starting the interviews, I realized that my focus on cultural beliefs was far too narrow. Stories about infant and young child feeding were situated within other narratives of violence, suffering, and various forms of intergenerational trauma. It became increasingly clear to me that it was impossible to disentangle cultural beliefs and practices around infant and young child feeding from the contexts in which these practices occur.
As I listened to their stories, I realized that I had been looking in all the wrong places to understand breastfeeding inequalities in Hawai’i. I failed to consider historical trauma, the cultural context of grief and shame, gender-based violence perpetuated generation after generation, substance abuse that infects families and communities, and the grinding poverty that leads to chronic food insecurity and homelessness. Most days I left these families thinking to myself that breastfeeding was the least of their worries. The chaos of their lives made breastfeeding promotion seem pretty insignificant.
But, is it really insignificant?
Breastfeeding is integral to maternal-child health. In order to get a handle on breastfeeding disparities in Hawai’i, one needs to examine the social context of everyday violence that leads to maternal and infant morbidity and mortality. There is little arguing with all of the potential benefits of breastfeeding for improved community health. Breastfeeding isn’t simply a behavior to support, it is integral to improving maternal-child health outcomes. But, it seems somewhat unrealistic to think that breastfeeding rates will be improved as long as high rates of perinatal intimate partner violence, substance abuse and addiction, child sexual abuse, and mental illness persist. The mothers I interviewed described many reasons for giving up on breastfeeding, including medical contraindications or if they feared that breastfeeding would put their child at risk of harm by violence, for example.
To further complicate things, the public health and ethnographic evidence point to breastfeeding disparities as syndemic with metabolic syndrome, perinatal mood disorders, infant mortality, and violence and social suffering in Hawai’i. Breastfeeding is a biocultural process, and it’s difficult to disentangle social factors with physiological ones when trying to understand why breastfeeding works for some but not for others. When disrupted lactation is considered as part of a syndemic, it no longer makes sense to use targeted interventions for these issues as if they are separate entities. Preconception obesity, insulin resistance, and perinatal mood disorders may all have deleterious effects on lactation physiology, even when mothers have excellent breastfeeding support and are doing everything they possibly can to make breastfeeding work. NHPI women are more likely to experience co-occurring physiological, psychosocial, and structural “barriers” to breastfeeding than others in Hawai’i. As a result, the kinds of education, support, and care they may need to initiate and continue breastfeeding may be quite different from that which has been successful in other groups.
What I learned from these families was that homeless NHPI breastfeeding mothers and babies face unique challenges. They have special needs associated with historical trauma, structural violence, and social suffering, which are largely being unmet. Finding ways to prioritize access to breastfeeding education and support for homeless mothers and babies is important. Pregnant women and those in their immediate support network would greatly benefit from breastfeeding education and support as well. At the same time, parents/caregivers who are homeless and are bottle feeding also need considerable support to ensure that they have the resources needed to safely feed their babies. This is particularly true for those living in emergency-shelter settings or on the streets where sources of clean water, refrigeration, and access to safe complementary foods may be hard to access.
Participants’ stories reveal that parents who are homeless and have babies in their care, regardless of how they are feeding them, would benefit greatly from increased support for how to meet their babies’ emotional and physical needs with limited resources. The anxiety and shame that surrounds homelessness have led many parents to cut ties with supportive family members and friends, which often exacerbate feelings of hopelessness and isolation. Providing opportunities for parents to learning about typical infant behavior, feeding cues, soothing techniques, and other infant caregiving practices may be valuable to family well-being, perhaps in ways that can’t be easily measured. Shelter and food are not the only basic necessities that families require, particularly families with young babies. The good news is that there are already these types of programs and services available in Hawai’i. But, greater coordination of social services, health services, and infant feeding support is needed to meet the unique challenges that many homeless families face.
When breastfeeding isn’t working out or isn’t possible, there should be universal access to safe donor human milk to all babies. Human milk provides optimal nutrition for babies. There are currently no HBMANA or other milk banks operating in Hawai’i. Breastfeeding rates in Hawai’i are stellar. There is a huge potential for donor human milk to reach the babies who need it most, including the disproportionate numbers of NHPI babies who are born pre-term or dealing with health conditions that undoubtedly lead to the higher infant morbidity and mortality rates documented in these groups.
Still, the physical healing will not be sustainable as long as the cycle of historical trauma remains unbroken. There is a need for family-centered medical care and social services that promote population health simultaneously with community healing, well-being, and revitalization. Eliminating health disparities requires addressing the causes of inequality and social suffering. This is no small task. Doing so requires structural interventions, not simply health interventions. It requires caring for physical health as well as well-being. It means that the balance of power needs to shift such that health and healing begins within the community at the hands of those within the community to meet the goals and aspirations set by the community. It also needs to happen within a society in which access to health services is treated a basic human right, not a socioeconomic privilege.
There have been great strides in addressing NHPI health disparities in Hawai’i. Community-based health care, specialized educational and research programs, and health interventions designed and implemented by NHPI have been established and have proven effective. Yet, there is still more work to be done in addressing maternal-child perinatal health inequalities in Hawai’i. Expanding family-centered care to homeless NHPI families may be an important step towards achieving this goal.