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OBS Case Study - Bushra, Peer Supporter

Bushra breastfeeding with her older children playing around her

Bushra with her daughters

Breastfeeding as a Muslim British-Pakistani/Kashmiri: 6 Years and Counting

My name is Bushra and I am a mother to 3 amazing girls alhamdulillah (praise be to God). I am of Kashmiri-Pakistani descent. My grandparents emigrated to the UK and so my mother gave birth to 6 of my siblings in England, whilst I, as the eldest, was born in Kashmir.

I graduated from the University of Bradford with a degree in pharmacy and considered myself to be well informed about pregnancy and healthcare in general. I read lots of things to prepare me for the life changing moment that is having your first child. I thought I was ready for what was to come and yet there was a chasm between how well prepared I thought I was and the reality.

During my pregnancy I decided that I did not want to give formula to my baby at any cost. In the Quran there are numerous references to breastfeeding the most notable in chapter 2 (Surah Baqarah), verse 233 where God states:

“Mothers may breastfeed their children two complete years for whoever wishes to complete the nursing (period).”

Breastfeeding was deemed so important to God that even the duration was explicitly given in the Quran. I also read a book called Heaven Under Your Feet: Pregnancy for Muslim Women by Umm Hasan bint Salim which has a comprehensive section about breastfeeding. I read medical articles stating the health benefits of breastfeeding both for myself and my newborn and journals with vast amounts of information about the amazing qualities of breastmilk as a living, ever-responding, live, immune-boosting liquid gold. My husband was supportive of this decision. I was also vehemently opposed to formula brands and their aggressive and unethical marketing strategies after reading information on www.babymilkaction.org and through the film Tigers. I attended an antenatal workshop about breastfeeding, had conversations with my midwife about my intentions and had all the literature that I was supposed to receive. In the end none of these helped me.

Towards the end of my pregnancy I suffered with pruritic urticarial papules and plaques of pregnancy (PUPP) or polymorphic eruption of pregnancy (PEP). It is an extremely itchy rash which develops on a person’s stretch marks and for me, spread everywhere. It usually resolves upon delivery, but I had it for more than 8 weeks post birth.

My daughter was born in the evening at the JR hospital with no complications. She latched on after birth really well and I was overjoyed. When family came to visit, she was still feeding and I felt some uneasy pressure that I needed to take her off to introduce them all. I let her finish naturally and felt relieved when she did, so that they could all see her. It was here that I was asked, ‘shall we give her a bottle?’ I politely refused and said she was nursing well. I stayed overnight in the hospital and remember joking the next day to everyone who called to ask how the night was, that she was a talker like her Ami (mama) and an eater like her Abu (dad). She had fed and cooed all night it seemed to me!

When I went home the difficulties really started. I still had the itch and was having little to no sleep because of the severity and having to feed. I was taking the maximum dose of antihistamine and paracetamol just to feel slightly comfortable. My little bundle of joy was of the kind that liked to nurse for 40 minutes or more and then have another feed equally long after only an hour or two! The comments started coming: ‘you don’t have enough milk for her’, ‘why does she take so long?’, ‘how can she be hungry again?’, ‘you just fed her’… It was too much to bear!

I was unable to go downstairs and be presentable to all the well-wishers who were coming to see the baby and me. But I still had to. In my culture it is completely unacceptable to not go and see guests no matter how much pain you are in, how tired you are or how far into the feed the baby is. I still remember once I went down before I started feeding so that the guest could see the baby and she looked at her and said ‘your baby is hungry’. I just looked blankly at her but inside I was seething!

She was also very petite (as I am) and was on the 25th percentile at birth and actually dropped even further down to near the 2nd where she levelled out. I was obsessed with this stupid chart. I would take her weekly to get her weighed. Again, this was because of the non-stop criticism that I was getting about not having enough milk – I needed to prove that she was ok and that I was enough for her.

I didn’t really know anything substantial about breastmilk production and decided that when breasts are full it meant that there was lots of milk there. I’m not sure where I got this idea from and it is actually the complete opposite of how milk production works. For this reason, I fed her from one side repeatedly until the other side was full and then vice versa. I hand expressed to check that milk was coming out and was ‘there’. I was never able to express more than 2 ounces of milk, even months down the line. I had absolutely no confidence in my body to be able to produce milk.

In addition to all the above, my daughter did not like to sleep. I was the kind of person that always went to bed by 10pm and woke at 7am so I was not ready for this! I desperately tried to get her to sleep in the Moses basket. It was exhausting. As soon as I put her in there, she knew it. She was awake and then I would rock her back to sleep to put her back in there only to repeat the cycle. The day that I moved her into my bed, at around 5 weeks old was the day I regained a little bit of sanity. I ticked all the boxes for safe co-sleeping and we both finally slept a little. In addition to dealing with this lack of sleep were the constant remarks of ‘she is hungry, that’s why she doesn’t sleep’, ‘she needs formula’, ‘I’m going to buy a bottle and give her some when you aren’t there’. I was frazzled and when I look back, I definitely suffered with depression although I would not have admitted it at the time. I also did not know how to feed whilst laying down. I cannot believe that for 5 weeks I fed every single feed sitting up in the day and during the night because I didn’t know there was another way.

There was not a single person in my extended family from my generation, or the one above, or in my friendship group that had exclusively breastfed a baby without expressing. I had no one to ask for help. I feel sorry for my mum’s generation. They have been so brainwashed by the policies and experiences they had in hospitals in England in the 80s and 90s. They thought they were being helpful by suggesting combination feeding or full formula feeding – that it would make my life easier, that someone else could feed the baby, that I could get some well-deserved rest, that it didn’t make a difference to my baby if she had some formula… They were not supportive or understanding of my choice and could not help me. In the end I just put up a wall of indifference to everyone.

If I hadn’t been so determined to boycott formula companies and to fully breastfeed, I would have given up here. As it happens, I was stronger than I could possibly imagine.

I will never forget the first Friday that I walked into the main room at the Florence Park Children’s Centre to go to the Baby Café (now called Oxfordshire Breastfeeding Support) where I found a group was running to provide breastfeeding support for women.

I nervously took a place on one of the sofas and cradled my baby. I waited until it was my turn. When Lisa turned to me, smiled and said ‘Hi’, I cried. I sobbed. I was so embarrassed to cry in front of a group of women that I didn’t know. But she gently carried on. There are some special people on this Earth and Lisa is one of them. I blurted out my problems. And she carefully unpicked my mess of words and gave me solutions. I said to her that my baby wasn’t growing. She responded that she looked beautiful, happy and healthy. I said that she didn’t sleep well. She said that all babies are different. I said I didn’t think I had enough milk. She asked me why I thought that and then went through a checklist of things to look out for. Things like is the baby weeing and pooing enough? Is she alert and happy? I could finally see through the haze. She didn’t ask me any numbers. She didn’t need to know how much my daughter weighed or how many hours she slept. She knew what mattered. She also taught me how to nurse laying down. I could finally rest and feed at the same time.

As the week went by, I crumbled under the pressure of those around me still questioning my choice to exclusively breastfeed, the weight gain of my daughter and her minimal sleep. But every Friday I got my boost. I was told that I am doing well and there was nothing to worry about. My questions flowed better and were answered in the most caring and compassionate way. I never felt stupid for asking something or felt that I was supposed to know the answer.

And so life went on. As the week went by, I crumbled under the pressure of those around me still questioning my choice to exclusively breastfeed, the weight gain of my daughter and her minimal sleep. But every Friday I got my boost. I was told that I am doing well and there was nothing to worry about. My questions flowed better and were answered in the most caring and compassionate way. I never felt stupid for asking something or felt that I was supposed to know the answer. I attended Baby Café well until past my daughter being 1 years old. I made friends there and our children grew together.

Lisa asked me to become a peer supporter and I agreed. I did the training and was armed with a wealth of knowledge. I felt invincible. I could break down old myths that were like weeds surfacing again and again. I was a regular at the Friday sessions. I never quite felt comfortable to check a latch or advise in that regard but I was able to offer emotional support. Sometimes that is enough to solve at least 90% of the issues that people have – I know it was for me. It was at this point that it dawned on me just how lacking my pharmacy education was in regards to breastfeeding. I don’t remember even a one-hour lecture devoted to the topic. Pharmacists are so well placed in the community to provide support to mums and babies as there is a dedicated, private consultation area in every community pharmacy. It seems such a wasted opportunity to not tap into this amazing resource that already exists nationally.

I exclusively breastfed my daughter until 2 years old. My struggle towards the end and her feeding up to 5 times a night until the week before she turned two are for another time! She is 6 years old now and I look back with fondness at the beautiful journey that we shared and feel indebted to Lisa.

Nearly 3 years later I had my second daughter. This time I was ready! I had all the information I needed and past experience. It was going to be a breeze! But it wasn’t. I had an oversupply of milk which resulted in my daughter choking every time. She suffered with high levels of jaundice and was extremely difficult to wake for feeds. I remember expressing 7 ounces of milk because I was so engorged only to throw it away because I couldn’t give it to her. It was a difficult first week or so after which things mostly settled down. At least this time I didn’t get the questions (although the looks and assumptions were still there). I guess people thought I wasn’t going to listen anyway so there was no point. It didn’t bother me anyhow and I was happy to be seen as stubborn and unwilling to listen in this regard. I had my priorities and I wasn’t going to budge. My daughter was so easy this time! She drank milk for a maximum of 15 minutes every 3 hours on the dot. She slept well, took regular naps and stopped night time feeds herself around 1 ½ years old. My husband patted her to sleep one night when I was sleeping with my older daughter and she went back to sleep! I never looked back and completed 2 full years of nursing.

Fast-forward another nearly 3 years to baby number 3! I made rookie mistakes. I managed to give myself blisters in the first 24 hours in hospital. Feeding a toddler is completely different to feeding a newborn and I had forgotten the basics. How to hold her head, how quickly to latch her so her mouth was still open wide, how her bottom lip should be turned out. I couldn’t believe that I could get it so wrong – I had fed 2 babies before and had been helping other mums with feeding! One night about 2 days after she was born, I had the most painful feed I have ever experienced in my life. It was like I was being cut with a knife with every suck. I cried through the whole feed. I was awake in the morning and needed to feed again on that side and was dreading it. I knew that I needed help and that I needed to fix it before my husband’s paternity leave finished in 8 days. I lived close by to Florence Park Children’s Centre where the community midwives were based. I called in the morning and demanded to be seen. I knew that my whole breastfeeding journey was in jeopardy with this next feed. When I say that one feed can be the difference between carrying on and giving up, this is what I am talking about. This is why timely help matters. I was referred to other services like OBS but they were not until later in the day. I needed help then. Not in a few hours. I must have sounded crazy and I probably was in my desperation. The poor midwife said she had 10 minutes before her next appointment and that if I could get there, she would see me. I got ready as fast as I could, put my baby into a carrier, grabbed my notes and hurried downstairs. As you can imagine it was quite a shock for my husband and mother in law who had no idea what was going on. I shouted out that I was going to the midwives in the park and that I would be back. I ran out of the house and marched to the centre. The midwife had a look at my latch and helped me feed rugby ball style. Although it was still painful it wasn’t like it had been the night before. Her bottom lip was in a different area and so it was giving some relief to where I was sore. I was referred to the JR hospital feeding clinic and went home relieved to know that it was going to get better. When I went to the JR, I was reminded about the bottom lip being turned out. When I looked it was barely out – she had learnt a bad latch. I pushed her chin down to try and correct it like they taught me. Over the course of the next few days things slowly got better. The lady at the feeding clinic said that even a couple of mm can be the difference between a painful and painless latch and that things would also improve as she grew and her mouth got bigger. She was right. By the time my husband went back to work I was pain free and happy. She feeds and sleeps somewhere in between my first and second daughters. She is nearly 1 ½ and we are still enjoying a lovely feeding relationship.

Since that day to now there have been at least 7 babies in my immediate family that have been exclusively breastfed way beyond the 6 months and mostly closer to 2 years. I have normalised breastfeeding to those in my generation and the ones below. My children, nieces, nephews and cousins know that babies are fed by their mums. 

As my knowledge base has increased, I have supported many mothers. My family, my friends, women I don’t know in group message chats I am part of and even women in person in Oxford who have reached out and been directed to me through friends. I now feel confident to check a latch and decide if further help is needed. Since that day to now there have been at least 7 babies in my immediate family that have been exclusively breastfed way beyond the 6 months and mostly closer to 2 years. I have normalised breastfeeding to those in my generation and the ones below. My children, nieces, nephews and cousins know that babies are fed by their mums. I feel so blessed by God to be able to support mothers in this way.

The journey above is my personal journey with breastfeeding. There are many common struggles that I have seen arise time and time again where Muslim mothers, especially from a British-Pakistani/Kashmiri background face, despite breastfeeding being strongly recommended in Islam:

1. Family pressure and expectations

This is a huge issue. Because of a lack of education and many myths about breastfeeding in my parent’s generation there is so much misinformation. The ideal situation presented is to combination feed. This allows maximum convenience. During the day you would bottle feed to allow you to cook, clean and keep your day much the same as it was before and during the night you would breastfeed so that you could get better sleep and there would be no need to get up in the middle of the night and make a formula feed. There is such a huge pressure to keep up normality. To still have a clean and presentable house, to stay on top of laundry, to cook and eat well and serve guests. This can be hard when living with extended family, and even more so when living alone where you are the only person to manage all these tasks. There is also the question of ‘what would you do if you had to leave the baby and go? How would we feed it then?’ I never understood just where I would need to go that I wouldn’t be able to take my infant with me. Many times I heard, and personally experienced, family members feeling left out and like they couldn’t bond with the baby because they weren’t able to ‘help’ with feeding.

The best way to tackle all these issues is communication. Discuss your intentions before you have the baby with those who are around you. Try to have your husband on board and fully supportive of your decision. He can be your intermediary. Find out together just what breastfeeding requires and how time intensive it can be (depending on the baby of course) in the early days, and even later on. Make it known that there may be hours when the baby is cluster feeding or having a growth spurt where you may be feeding all evening and that this is normal and to be expected! This all helps to set a realistic expectation. Surround yourself with people who are supportive of your decision – they can and will be your voice against the critics. Ask family members to burp and change your baby and to have cuddles so they are still able to bond.

2. The difficulty of trying to feed whilst living in an extended family

It is extremely difficult to maintain modesty and not experience loneliness. I felt like a prisoner in my bedroom sometimes. I was isolated from everyone else and day-to-day life as I couldn’t sit in the living room and feed there. This is especially pertinent in the early days when both the mother and the baby are still learning how to feed. It is not possible to feed with a cover and so the only option is to feed by yourself. I recommend having your books or TV, water and snacks to keep you going through these moments. If you have anyone who can keep you company (and you are comfortable with their presence while you feed) ask them to do so. It can be even more difficult when you have other children and they want you to be part of their day. Try to ensure that someone else can support you through this time.

3. Unexpected visitors

As soon as a person returns from the hospital well-wishers start coming. This is actually really difficult to manage. Many times, over the course of the last 6 years I have delayed a feed, or cut one short. People need to understand and be respectful of the needs of the mother and baby. The least one should do is to call ahead and pre-arrange a visit.

4. Feeling uncomfortable when not covered

Modesty is very important in Islam. I know that I found it extremely uncomfortable to feed in the presence of my sister in laws, mother in law and even my sisters in the beginning. I felt exposed. Many of them didn’t have children and felt even more awkward than I did! The feeling doesn’t last long I can assure you. It becomes second nature and neither you nor your female companions will bat an eyelid. As your baby grows and you both become more comfortable with feeding you can cover yourself with a baby cover, or even a shawl / hijab draped over the baby which can definitely help with this.

5. Feeling awkward feeding your baby in front of male members of the family such as father, brothers

Many mothers have said to me that they feel awkward that the men know what they are doing even if they are wearing a cover. I personally do not understand this. I remember my mum sitting and feeding my youngest brother at the end of the settee with everyone else around and it was completely normal. She was covered with a shawl and we all played and the men talked. I think this is unfortunately a problem that has arisen with my generation and I don’t really know why. Maybe because my generation hasn’t been exposed to their mums and aunties breastfeeding so that natural passing down of information and experience has been lost? Maybe the perception of what female bodies are for has changed? I’m sure there are many facets to be explored. When people have asked me my opinions about it, I said that I am feeding my baby and covering modestly. I’m not doing something dirty or disgusting that I need to go away and if it offends someone so much then they should have the decency to go somewhere else themselves. Mothers should have a safe space in Islam to do what they need to do and breastfeeding is a command of God.

6. Traditional family structures

Some males (and females) expect women to carry out all the household tasks and there is no slack given for illness or birth. When the mother is feeding, especially in the early days, she is not able to do housework or other duties. I believe there is a reason for this – because you need rest! Make sure that you get all the help you can from your family and friends. I found that a sling was useful to carry the baby and get on with my day, especially when I had older children. Unfortunately, slings are frowned upon in some families or there may be no prior experience of using one. I know that both my parents and my parents-in-law did not like mine. They said I was spoiling the baby by carrying her so much. But I felt so much freedom. I could do what I wanted and eventually even mastered the skill of feeding in the sling whilst still being covered! I also felt that my little baby was a part of our family day. Over the years they have become used to it and it is a new norm.

7. The lack of structure

Before a feed starts it is impossible to say if it is going to last 5 minutes or 45 minutes. Many people I know and have spoken to find this really hard to manage. We grow up in a society and live a life that is very controlled and regimented. We know what we are going to do and when we are going to do it. Our education is linear – we move from one step to the next. Having a baby is a complete shock to the system! The graph is not smooth – it goes up and down, backwards and loops the loop! I say embrace it with your arms open wide. Expect the worst because then it can surely only be better. Let go of all expectations and just be. This time will pass all too quick and we shall long for (most of) it again.

8. There is a need to know how much milk the baby has

For some reason there is an insane obsession with figures. How much the baby has drunk, how many times it drank, how long the feed was, what was the gap between feeds… I say there is a reason why we don’t know this and God knows best. Our body is capable of growing a human AND providing the best nutrition for this little being!

9. The baby is too skinny

Well-fed babies are expected to have fat rolls and anything otherwise is not acceptable. I had to deal with this a lot and it completely undermined my confidence in myself and my body to be able to produce milk. It put me on guard about anything that was said to me and really made me quite depressed. I don’t think that people understand just what they are questioning when they say this. They are questioning whether you are enough and that makes you feel like a bad mother who can’t even provide milk for your baby. My sister had a baby when I had my second daughter and she also exclusively breastfed. Her baby was on the 75th percentile and tall like her, and mine was again on the 25th and short like me. As they say, the proof is in the pudding.

10. The ‘normality’ of buying bottes, sterilising equipment etc. as if it is an essential baby product much like one would buy clothes

Whenever I looked at baby catalogues there was a never-ending section with hundreds of products devoted to bottle feeding – whether expressing or formula. I remember when I had my first baby my sister was only a teenager and she was so excited about a steriliser. She said it was the thing she most looked forward to buying! We all laughed at her as you can imagine. When you look at dolls and children’s toys, they are always supplied with a bottle. It is just so normal. I remember buying one of everything in case I needed it and then a couple of weeks before my due date I went and returned everything! I didn’t need a ‘just-in-case’… I was going to give it my all to make it work, and if it didn’t then someone could pick up things for me.

For me breastfeeding has meant freedom! I have never had to worry about making a bottle in my life, or even worse washing and sterilising everything! I didn’t have to remember to pack all the different components. I have travelled with my children and published my first children’s book, My Islam A-Z with my little ones in tow… the easiest time was when they were under 6 months so I didn’t have to worry about where I was going to buy food for them! When the lockdown happened, I wasn’t worried about where I would buy the next box of formula. I wasn’t reliant on anything or anyone else. The more children I have had, the more grateful I am to be breastfeeding. Life is busy with toddlers, work and housework. The real moments of bonding that I had with my newborn were during the times I fed her. If the option of a bottle was there, I am sure that on many occasions I would have just passed it over to someone else so I could tick another thing off the to-do list. Breastfeeding made me sit down, put my feet up and be 100% present with my baby.

My biggest supporters were people in my grandparents’ generation. Mothers who fed their babies breastmilk in their homeland with no other option. They told me they were proud of my decision and I was doing the best thing for my daughters. That my daughters would grow up to be healthy and strong and not get ill so easily. My father in law was also really encouraging. I remember him saying that I was welcome to feed downstairs with a shawl to cover myself when my first daughter was born.

Whether someone choses to formula feed or not is their own decision – it should always be an informed choice and not a necessity because there was no help with breastfeeding. I want to say a huge thank you to the OBS team. You are providing a lifeline to mothers each and every day. Thank you for giving me this knowledge which is power. 

I pray that no mother is ever forced to make the decision to formula feed because they weren’t able to access support or the correct information in a timely manner. Whether someone choses to formula feed or not is their own decision – it should always be an informed choice and not a necessity because there was no help with breastfeeding. I want to say a huge thank you to the OBS team. You are providing a lifeline to mothers each and every day. Thank you for giving me this knowledge which is power. The biggest thank you to my husband who has supported my decision every time and has had to bear most of the burden apart from myself.

August 2020

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