Multidisciplinary Study on the Socio-Cultural Barriers to Breastfeeding and on the Health of Children and Adolescents Immigrated in Italy from Latin America and Europe

Miriam Castaldo^*, Concetta Mirisola, Daniela Feria, Laura Piombo and Rosalia Marrone

National Institute for Health, Migration and Poverty (INMP) Via di San Gallicano, Rome, Italy

*Corresponding Author:

Miriam Castaldo
National Institute for Health, Migration and Poverty
(INMP) Via di San Gallicano, Rome, Italy
Tel: 393392203360
E-mail: castaldo@inmp.it

Received date: June 07, 2016; Accepted date: June 13, 2016; Published date: June 18, 2016

Citation: Castaldo M, Mirisola C, Feria D, Piombo L, Marrone R (2016) Multidisciplinary Study on the Socio-Cultural Barriers to Breastfeeding and on the Health of Children and Adolescents Immigrated in Italy from Latin America and Europe. J Preg Child Health 3:260. doi: 10.4172/2376-127X.1000260

Copyright: © 2016 Castaldo M, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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Abstract

In the context of the project Clinical and social evaluation of medical practices in the treatment of infectious diseases in paediatrics for children of vulnerable populations carried out in 2012-2014 by a multidisciplinary team at the [name deleted to the review process] a study in medical anthropology was conducted. The research targeted 75 children and adolescents immigrated to Italy from Latin America and Europe. The study aimed at analysing the sociocultural representation of women regarding: barriers to breastfeeding, the impact of cessation or non-cessation, and the effects of breastfeeding on the psychological and physical health of infants.

Keywords

Breastfeeding; Migrants; Health; Medical anthropology

Introduction

The health benefits of exclusive breastfeeding with milk from the infant's mother for a period of six months, mostly during the first 28 days post-birth [1,2] to achieve optimal development and health are well documented in medical research [3] it suffices to mention that, of all health protective interventions, regular breastfeeding of infants under two years of age has the greatest preventive impact on child survival [4]. Moreover, breastfeeding has relevant implications for the health of mothers [5,6] and for the mother-child relationship [7].

Despite this, social, economic and cultural barriers [8-10] in some socio-geographical areas, may lead women to suddenly stop breastfeeding.

Early cessation of breastfeeding has adverse health and social implications for women and children. As a result, these produce greater expenditure on the national health care provision, and increase health inequalities.

In Latin America 38% of infants are exclusively breastfed during their first six months of life children in Latin America and the Caribbean are breastfed on average for 14 months, though as with other breastfeeding practices, there is great variability in the duration: the average is seven months in the Dominican Republic and Uruguay; 18 months or more in Bolivia, El Salvador, Guatemala, Honduras and Peru; 14 months in Brazil and 10 months in Mexico [11].

Where data is available for European countries breastfeeding rates for babies aged three months range from 22.7% to 97.6%. By six months of life, rates fall significantly, although progress has been made in many Member States of the WHO European Region [12]. In Romania and Albania, the European countries most represented in the research, mothers who breastfeed their babies, in Romania only 12.6, are fewer than in most other European Countries. In Albania the total number of exclusively breastfed children at the age of three months has decreased in time. According to the survey published by the Albanian Ministry of Health, the rates of exclusively breastfed children from zero to three months has decreased dramatically: from 35.300 in 1993, to 22.800 in 2000, and down to 15.700 children in 2010; 36.9% of children from zero to six months are exclusively breastfed and at the same time the number of children artificially fed has increased.

In numerous non-western contexts women seem to incorporate the moral blame of psychological and physical illnesses which occur, and represent the signs of these illnesses on the body of their children starting from their birth [13]. This happens when women who are breastfeeding undergo traumatic experiences, which they think can affect their milk, in their native context, before emigration. These are: individual or collective violence, torture and abuse; private forms of violence such as psychological and physical abuse and beatings by their partner [14-17] the death of a family member or of a community member furthermore these experiences include persecutory supernatural-magic factors, identified by the hispanophone Latin American women interviewed as susto (“fright”) [18-25]. coraje [26,27], mal de ojo (“evil eye”), muina and enojo (“anger”) [28] by European women, only Albanian, as syri i keq, in the Tosk language, syni keq in the Gheg language (“evil eye”) [29]. Such concepts in hispanophone Latin America and in the Mediterranean region indicate feelings of envy capable of causing illnesses such as mal de ojo, anger or resentment like enojo, muina and coraje, and finally of causing feelings of fear and fright as is the case with susto. The latter is described in literature also as a culture-bound syndrome, a semantically complex concept in that the same signifier susto can indicate both an illness and an etiological factor [30]. Represented as an illness it seems to appear following a strong emotion and a threatening or sudden impression, natural or supernatural, and can especially impact women and children resulting in illness. Albanian women are the only women among the European women interviewed to have reported persecutory magic agents which are defined using the concepts of syri i keq and syni keq (“evil eye”); similar to mal de ojo; this concept refers to a feeling of envy that translates into the malevolent stare that intentionally aims to damage the person it is directed against.

Women believed that they involuntarily pass on to their children, through their milk, the suffering, the violence and traumas they have been subjected to [31-33]. In order to prevent their children from coming into contact with “bad” milk, and consequently getting ill, these women feel they are forced to suddenly interrupt breastfeeding [34]. The cessation does not however always occur in time to avoid contagion [35,36]. It is in fact possible that a mother does not realize in time that a traumatic experience, caused by a natural or supernatural event, may have damaged the quality of her milk, with the result that she continues to breastfeed.

Considering such obstacles to breastfeeding, and the consequences, both biological and social, that the cessation, or the non-cessation, of breastfeeding may have on children, on mothers and on the nuclear or extended family, it is evident that health services of countries that are the destinations of migrants need to provide access to culturally appropriate care and health professionals who possess the necessary cultural competence to support migrant families that are carriers of other illness semantics, other complex needs relating to health [37] different from the ones of the native population. The risk of not developing these skills and failing to recognize the role played by culture in the economic, social and historic context of health care is the shortcoming in health care interventions. The lack of contact between the culture of migrant citizens and the culture behind the health services of the host country may lead to a low level of compliance with diagnostic and therapeutic procedures which may be prescribed by the physician [38-40]. It may also cause citizens to turn away from National Health System (SSN), strengthening on the one hand the barriers to the right to health [41] and leading on the other hand to an increase in excessive and unnecessary requests for health care in the Emergency Room, where migrant citizens seek help, causing expenses in health care to increase.

Objective

The present article reports the findings of a prospective study in medical anthropology carried out over a period of 18 months from 2012 to 2014, aimed at analysing the formation and the socio-cultural representation, which emerged from the interviews with women, regarding: barriers to breastfeeding; the impact of cessation, or vice versa of non-cessation, the effects of breastfeeding on the psychological and physical health of infants; the social and domestic consequences which affect women who did not stop breastfeeding when they feel they should have.

Materials and Methods

The study in medical anthropology was carried out in the wider context of the project “Clinical and social evaluation of medical practices in the treatment of infectious diseases in paediatrics for children of vulnerable populations” conducted at the [name deleted to maintain the integrity of the review process]. The project was completed by a Trans disciplinary team formed by an infectious disease specialist, a medical anthropologist, a paediatric nurse, a paediatric neuropsychiatrist, a child and adolescent psychologist, a social worker and cultural mediators. The eligibility criteria for the sampling required children between the ages of three and 17 to have been born in Europe or in Latin America and to have immigrated to Italy for socio-economic reasons no longer than two years earlier to join relatives emigrated previously, or with only one parent. The families were contacted by the staff of the project at: the [name deleted to maintain the integrity of the review process] outpatient hospital; the family homes for mothers and children in [name deleted to maintain the integrity of the review process]; occupied housing; residential facilities inhabited mostly by Roma and Romanian citizens. The anthropologist interviewed only women, mothers of infants and adolescents, in private to ensure confidentiality. The conversation was never forced so as to respect feelings, emotions and provide the time needed by each woman interviewed and by the family member with her, especially children who, during the interview with the mother, waited with the father when present, with the social worker, with the child and adolescent psychologist or with the paediatric neuropsychiatrist. Adolescents instead waited outside the room while their mother was being interviewed. According to the Declaration of Helsinki, written informed consent was obtained from each participant included in the study, before interview.

The interview covered 37 items, open and closed questions, and was translated simultaneously by the anthropologist into Spanish and by the cultural mediators into the following languages: Albanian, Romanian, English and Portuguese. Women who preferred to use Italian were interviewed in this language; furthermore before starting the interview the women were asked what language they preferred to communicate in and whether they agreed to the setting which often brought together the anthropologist and a cultural mediator.

In the course of the study 106 children were contacted, welcomed, visited by the medical staff responsible for the project in accordance with the National Working Group for Immigrant Children (GLNBI) diagnostic protocol [42]. First child examinations took place in the paediatric infectious diseases clinic where the medical referent for the project also explained to the families the GLNBI protocol for examining immigrant children (Table 1).

Table 1: National working group for immigrant children’s diagnostic aiding protocol for international adopted and immigrants children (2007).

This protocol recommends collecting the medical history, often poorly documented especially for immunization status and also performing a complete physical examination and blood test in order to assess the children's health status and identify malnutrition, infectious diseases, psychological problems or other pathologies. If necessary, the protocol also suggests prescribing a specialist’s visit (paediatric neuropsychiatrist, oculist, dermatologist, otorhinolaryngologist, endocrinologist, surgeon, and cardiologist). Laboratory blood tests, performed by the San Camillo Laboratories in Rome, included QuantiFERON^®-TB Gold In-Tube (QTF test) aimed at evaluating any on-going or previous tubercular infection, serological tests for ongoing or previous HIV positive condition, Syphilis, HCV, HBsAg, anti HBs, anti HBc. A complete physical examination was performed and specialist visits were prescribed when necessary, in accordance with the protocol.

The mothers of 75 children were given an in-depth, semi-structured face-to-face anthropological interview which lasted about 45 min to 1 h. Each woman was interviewed once for each child. The interview was carried out with the mothers of 71% of the minors contacted during the project. It was not possible to interview the mothers of 31 minors for the following reasons:

• They did not come to the day hospital to pick up the results of the hematochemical tests of their children and it was not possible to make an appointment for the interview;

• It was decided the interview was inappropriate due to relationship problems in the family assessed by the child and adolescent psychologist;

• The appointments with the anthropologist were ignored;

• The husbands wanted to be present during the interview and did not allow their wives to speak to the anthropologist in their absence;

• Difficulties linked to the context such as language barriers or the inability of the cultural mediator to be present at the meeting.

Study Populations

The demographic sample is composed of 75 minor migrants, 37 female and 38 male, the average age of the minors is of 11. They were born in Latin American countries (Argentina, Brazil, Columbia, Ecuador, El Salvador, Honduras, Nicaragua, Paraguay, Peru, Dominican Republic, Uruguay, and Venezuela) and six in European countries (Albania, Greece, Malta, Monaco, Romania, Spain). 52% (39) are from Latin America, 48% (36) from Europe.

The minors arrived in Italy with different typologies of migration, the main types being: 40% (30) on their own, to join their family previously immigrated, mostly from Latin America; 33% (25) came with all the family, mostly from Europe, especially from Romania and Albania; 23% (17) came to Italy with the mother, looking for work and in search of social and economic stability; finally 4% (3) came to Italy with the father to join mothers and wives immigrated previously.

44% of the women interviewed has an occupation in domestic services or works as a domestic assistant (90% of these are Latin American); 56% is unemployed. Another significant difference between the women from Latin America and women from Eastern Europe concerns their marital status: 40% of the interviewed women are separated from their husbands and of these 77% come from Latin America and 23% from Europe. Also in the field of education there is a difference between the two populations: women from Latin America declared a higher level of scholarization. 8% of European women (six), all Romanian, are illiterate; 9.3% of European women (7), all Romanian except one from Malta, attended the elementary school; 8% of European women (6), all Romanian, attended the middle school; 40% of Latin American and European women (30) have a secondary school diploma (90% Latin American); finally 17.3% of women from Latin America (13) have a university degree, while of the remaining 17.3% (13) the level of scholarization is not known.

Results and Discussion

All the 75 children referred to our centre were without symptoms or evidence of illness at the time of screening, their mothers however spoke of disturbances with a distant origin.

We performed the screening by blood test in 58 children. We evaluated markers of HBV infection (HbsAg, anti Hbs, HbcAb), discovering 3.4% (2/58) undocumented recent past infections (defined by positive HbcAb) but no child presented chronic diseases (positive HbsAg) or HIV, Siphilis, HCV. QTF tests were performed on 40/75 children (53.3%), resulting in 12.5% (5/40) positive tests.

Mantoux Intradermal Reaction was performed only once (and was positive) because it was not possible to check the site of injection after three days. In our setting QTF were preferred because it was difficult for families to return after 72 h and because of its non-interaction with the BCG vaccine previously performed on most children from developing countries. Of the six children who tested positive to TBC screening three came from Romania, two from Peru and one from Honduras.

Parasitological investigation of faeces was performed in only one sample of 41 children (54.6%) and found positive in 4.8% (2/41) children infected with intestinal parasites. The isolated pathogenic parasites were Giardia intestinalis and Entamoeba histolytica.

With regard to non–infectious diseases, two children (3.4%) presented microcytic anaemias and 13 children (22.4%) eosinophilias.

The practice of breastfeeding reveals the suffering not only of the child but also of the mother and of the whole nuclear family, which appears to have participated in the construction of the loss of health in the child. This is what emerged and received care during the coordinated intervention of the medical staff and anthropologist, where it is evident that reference to the cultural matrix provides a strong therapeutic tool.

The interviews with the anthropologist assessed that 92% of the minors (69) were breastfed with certainty; one child was not breastfed, while in the case of five children it is not known whether they were breastfed (Table 2).

Table 2: Infant breastfeeding practice.

The duration of breastfeeding varies from one month to two and a half years, and nationality has no significant influence.

Barriers to breastfeeding perceived by Latin American mothers

The duration of breastfeeding reveals an interesting fact. Mothers in fact describe themselves as being responsible for illnesses and psychological and physical anomalies manifested by their children since birth [22], if during breastfeeding they are subjected to traumas such as maternal intimate partner violence (IPV), if they come into contact with invisible entities which alter and damage the nutritional values of the milk and if, as a consequence, they do not immediately and definitely stop breastfeeding. These traumas and invisible agents are identified and represented by hispanophone Latin American women with the concepts of mal de ojo, susto, enojo, coraje, muina while European women, only Albanian, use the concepts of syri i keq and syni keq (listed in Tables 3 and 4) depending on their sociocultural systems of reference.

Table 3: Problems encountered by mothers of 19 Latin-American children <3 month - 1-2 years based on interviews.

Table 4: Problems encountered by mothers of 19 European children <3 month - 1-2 years based on interviews.

These are not mentioned during medical examinations, as they are not only concepts expressed in a different language, and have a meaning only in that precise language, but are words that do not have a meaning for western biomedicine which is not able, on its own, to understand types of distress that are alien to allopathic nosology. It is important to highlight that women immigrated to Italy turn to the SSN expressing needs relating to the health of their children; these children are also immigrants, and have manifested such types of psychological and physical distress from birth, for which the mothers feel they are responsible.

Latin American mothers reported to have breastfed 38 children out of 39. Of these 33 were breastfed for a period of time that goes from one month to two years and a half, with no specific duration prevailing. The duration is not known for five children, their mothers did not answer the question because they said they could not remember. It is important to note that the mothers of 19 children reported that they felt forced to stop breastfeeding, and continued feeding with artificial milk, cow's milk or tea. Of these 14 stopped breastfeeding before their child turned two, and said they had done so to avoid passing on through the milk the traumas and suffering they were undergoing, and to avoid compromising the health of their child. This indicates a mother-child relation structured around the inheritance of contagion and on causal connection [41]. Five women stopped breastfeeding because of work related issues or because of insufficient milk.

The two main reasons given by the mothers for premature cessation of breastfeeding are:

• They suffered traumas, came into contact or were attacked by invisible agents which relate to the socio-cultural system of reference (susto, mal de ojo, coraje, muina, enojo);

• They were subjected to violence or psychological and physical abuse by their husbands, such as maternal intimate partner violence (IPV) [17,40].

Table 3 synthetically reports the reasons given by the women for cessation of breastfeeding.

Barriers to breastfeeding perceived by European mothers

From the interviews conducted with European women it emerges that 100% of children were breastfed for a period of time that varies from less than three months to more than two years (Table 4).

As is the case with Latin American women, it is worth noting that the mothers of 26 children declared they interrupted breastfeeding and continued feeding with artificial milk, cow's milk, water mixed with rice flour and baby meals. The mothers of nine children stopped breastfeeding to avoid passing on through the milk the traumas and suffering they were undergoing, and to avoid compromising the health of their child. The main reasons given are:

• Forms of distress which relate to the socio-cultural system of reference (such as syri i keq and syni keq) (triggered both by entities and spirits from the supernatural world and by members of the family who carried out violence and abuse);

• Fviolence and psychological and physical abuse by their husbands, in most cases alcoholic;

• Traumas following wars in their native context.

• The mothers of 17 children declared they had stopped breastfeeding prematurely because of numerous reasons not necessarily linked to the need to protect the health of their children from the suffering they had experienced.

• The following reasons were given by the mothers for premature cessation of breastfeeding during the interviews:

• They didn't have enough milk;

• They became pregnant again;

• They emigrated to Italy and left their children in the care of relatives who stayed in their native country;

• The onset of an illness in other children required their full attention.

• As above, Table 3 synthetically reports breastfeeding problems identified by the women interviewed.

With regard to the practice of breastfeeding, it is important to highlight that the number of women who stopped breastfeeding is remarkably high, from those who breastfed for less than three months to those who continued for up to two years. In fact only 11 women out of 56 (of which five Latin American and six European) did not feel it was necessary to interrupt and said they feel the duration of breastfeeding was optimal. Those who did not interrupt are the women who breastfed for more than two years, they account for 19% (13) of the total number of women who breastfed. These figures which relate to the duration do not appear to be influenced by nationality.

Nationality plays a role in other analogies and differences that emerge from the data collected. Latin American women work more in Italy compared to European women, for these women the unemployment and inactivity rate is higher; furthermore Latin American women have a higher level of scholarization, but are also more alone, as they reported more divorces and separations than European women.

Breastfeeding is the most cost effective way to decrease child mortality and morbidity in developing countries. In particular, breastfeeding is important for the protection of children against infectious diseases such as diarrhea and acute respiratory infections [21].

WHO stresses exclusive breastfeeding during the first six months as a key aspect in child survival interventions. Some studies suggest that breastfeeding may protect against ear, throat, and sinus infections well beyond infancy and have a positive effect on the overall development of the child, in particular on cognitive and motor development. Many surveys in developing countries suggest that interventions to improve early and exclusive breastfeeding would contribute to improving child health and nutrition [2].

Latin American mothers (14 out of a total of 19) report in a more significant way, compared to European mothers, the correlation between the cessation of breastfeeding and the supernatural world which relates to their socio-cultural system. Also European women link supernatural influences with cessation of breastfeeding, though in fewer cases (three out of a total of 26).

Although we can draw a distinction between the two populations on the basis of barriers relating to the supernatural world, European women (six out of 19) can be said to be very similar to Latin American women (6 out of 26) if we look at domestic violence (carried out by husbands in particular, and by relatives). These types of abuse and the repeated beatings are in fact an obstacle to breastfeeding because the intense feelings of fear and fright can damage the milk of women [17]. Although the phenomenon is reported to a greater extent by Latin American women (six out of 19) than European women (two out of 26), it is worth considering the power attributed to domestic violence that affects and damages the milk [27] making the women guilty of “poisoning” their children by not interrupting breastfeeding [8]. This highlights the conflict in the conjugal and intra-familial relationship, as well as in gender relationships. In fact women only are seen as being responsible for their children's illnesses and anomalies, because of socio-cultural norms they “were not able” to follow. The women interviewed said that the sudden interruption of breastfeeding was problematic in that they had difficulty in recognizing the exact moment they became object of attacks by supernatural agents, or the moment the domestic violence they were subjected to started to harm the milk; in fact with regard to domestic violence they pointed out that not all types of mistreatment leads to such damage [24].

In order to communicate these complex semantic constructions and mediate between the medical doctor and the child's family, so that a diagnostic and therapeutic plan can be prescribed, it is crucial to adopt a socio-sanitary approach which possesses the necessary social and cultural skills to assist and adequately respond to the needs relating to health of migrant families. In fact the anthropological contribution in the context of the activities carried out by the paediatric infectious diseases clinic constitutes a fundamental tool in that it allows to contact different health care ontologies and epistemologies, and to share them with the medical doctor with the aim of providing more effective assistance. The clinical setting composed of a medical doctor and an anthropologist also allows for an epistemological reflection on the invisible violence which results from not understanding and degrading non-western systems of thought, and on the need for a sanitary intervention able to contain the distress being expressed.

Limitations of the Study

In this research we report the experience of women from diverse cultural backgrounds, it would therefore be inappropriate to attempt to create one picture of migrant breastfeeding practices and barriers.

It was not possible to interview some of the women because they did not return to the hospital. The main reasons are: socio-economic (the cost of transport); they could not miss work; they had to be at school to pick up their children; also the lack of female autonomy, in fact some husbands did not allow their wives to go out on their own and did not consent to them being interviewed by the anthropologist in their absence.

The study also found that some barriers are linked to communication problems due to the absence of the cultural mediator.

Another bias of the research is that a large number of women, compared to the total, are Roma or Romanian. This fact is due to the word having spread inside one residential facility in particular; because of this, data regarding scholarization levels and employment is altered with regard to European women.

Finally, only Albanian women mentioned supernatural factors such as “evil eye”, against a very diverse sample of European women, especially Roma and Romanian. The data does not consequently allow concluding that among European women only Albanian women have an ethnosemantic background which includes influences of the invisible world, the results are in fact relevant only to the sample of mothers interviewed.

Conclusion

The need to enhance promotion, protection, and support of breastfeeding and of the mothers is indisputable. In fact the objective of the anthropology study carried out in the context of the project “Clinical and social evaluation of medical practices in the treatment of infectious diseases in paediatrics for children of vulnerable populations”, of which we reported the findings here, is to analyse, negotiate and provide assistance to the families expressing disturbances, in the light of socio-cultural processes, but also historic, political and economic processes relating to migration, which produce and reproduce marginalization and inequality, with the aim of building a therapeutic alliance for the psychological and physical health of children.

The needs expressed by the families of children with health issues are first of all a request for a relation, a request to share, that is often ignored in the clinic, where “non-objective evidence” is rarely taken into account, and where the personal history and stories of the patients, the real context of their lives, the sense of death they are immersed in, is often overlooked. The study wants to highlight that the risk of not contacting the cultural code of migrant families is the health systems' inability to manage childhood diseases and illness.

Because of our experience we believe that a significant economic impact on the health care system can result from knowledge and comprehension of different models of parental care, thus reducing improper actions in emergency rooms, the number of admissions to hospital, and unnecessary medical examinations.

In agreement with other studies and both Italian and international guidelines, an early and complete sanitary screening is recommended, at least in children from high risk countries and settings with low socio-sanitary conditions. Our data shows that only a minority of the children examined was negative to the tests performed and this points to how important an early diagnostic survey is in order to prevent the worsening of neglected problems which affect the child and the whole community.

Key Message

Medical anthropology collaborate to analyse, negotiate and provide assistance to the families expressing disturbances, in the light of sociocultural, historic, political and economic processes relating to migration, which produce and reproduce marginalization and inequality.

The risk of not contacting the cultural code of migrant families is the health systems' inability to manage childhood diseases and illness.

A significant economic impact on the health care system can result from knowledge and comprehension of different models of parental care, thus reducing improper actions in emergency rooms, the number of admissions to hospital, and unnecessary medical examinations.

Acknowledgement

We are grateful to the mothers who participated in this study. The project of which the current paper is a part was carried out with financial support from the Italian Ministry of Health.

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