Triumphant Tuesday - Breastfeeding in the Middle East

Parenthood is universal. All around the world, every minute of the day, men and women are becoming parents. Conception, birth, feeding – this cycle is unanimous. However the experience of parenthood can differ dramatically depending on the culture in which it unfolds. The following story provides a unique insight into how the experiences of getting pregnant, being pregnant, giving birth and breastfeeding unfold in the Middle East. Perhaps the West has a lot to learn from the Arab Emirates…


“The Arabic phrase “shway, shway” means something like “slowly, slowly” and is used in many different contexts, one being “take it easy” or “relax.” This seems to be the underlying lesson of the past few years of my life.

GETTING PREGNANT…

My husband and I decided to move to the Middle East two years ago when we were both hired as teachers in Abu Dhabi, United Arab Emirates. One of the biggest challenges for people in our situation is understanding the Arabic way of life, which is very laid back and relaxed, especially compared to the American way. Absolutely everything, from a trip to the grocery store to an appointment with a doctor or lawyer, is taken in a relaxed fashion. People often stop any and all activities, no matter how important they may be, in order to pray or to have a cup of tea together. Punctuality is appreciated but not crucial, and people tend to be flexible and adapt to new situations as they come. For expatriates from the West, this is hard to adjust to since we are programmed to value accomplishments and practicality, logic and punctuality, as if our lives are eternal “to-do-lists” and the faster we check things off, the better we are as human beings.

Before we left the U.S., we had followed this pattern. We got our college degrees and jobs, got married, and bought a house in Austin, TX. We adopted two dogs to prepare ourselves for the inevitable next step: parenthood. Only our bodies were not cooperating with our plans, and two years went by without a pregnancy. I tried a couple of cycles of Clomid, my husband had his sperm checked, but things were still not working out for us. By the time we decided to sell all our things and leave the country, we had put parenthood on the back burner and focused on the exciting adventures ahead.

Upon arrival in Abu Dhabi, we were immediately thrown into the whirlwind of moving into and setting up our new home, starting our new jobs, growing accustomed to the new environment and culture, making new friends, and just generally getting settled. For the first time in years we had stopped focusing on my cycle and the calendar and yet ….you know what I’m about to say don’t you?...this was exactly the time it finally worked out for us. Three months after our move I missed my period, reluctantly took a pregnancy test (I hated them since they were always a disappointment), and it came back positive.


PREGNANCY…

My first doctor’s visit to confirm the test was almost comical. I was so focused on getting pregnant before moving away that I never really read much about what happens past conception. All of a sudden I felt clueless. I was so used to American doctors who send you home with fliers, samples, websites to look up, and referrals, that it came as a complete shock when the doctor gave me zero information on what to do or not to do. He handed me a printout of my 5-week-old baby ultrasound photo, gave me a smile and just said “Mabrook (congratulations), see you in one month.”

After a few months, I found another doctor and a hospital I was happy and comfortable with. I joined a couple of online support groups for moms in the United Arab Emirates, hired a doula, met a few other expecting moms, and finally began to feel confident in my ability to have a baby so far from everything and everyone I knew. I did a lot of research and developed a strong sense of the kind of birth and parenting I wanted.

My pregnancy was mostly easy and lovely - at least the first two trimesters. Of course I suffered from the usual things: heartburn, exhaustion, nausea, back pain, etc. but nothing was bad enough to dampen my joy from finally being pregnant.

The last two months of pregnancy were definitely tough due to the fact that I was still teaching fifty-two rowdy, 4th grade boys, and also due to the fact that the hottest season of the year had begun. The summers in the Middle East are a grueling combination of stagnant air and relentless heat of up to 130 degrees F. It is so hot that even going to the pool or the beach is unbearable: inside the water it feels like a hot tub, and outside the water it feels like a steam room or sauna, depending on that day’s humidity index. I felt trapped indoors, breathing only artificial air, when all I wanted was to swim and go on long walks outside.

At last, the school year was finally over and my doctor approved my birth plan (natural and drug-free) as well as my placenta encapsulation, so it was only a matter of waiting for labor.  Three days before my due date, I went to the doctor because I hadn’t felt my son move all day. He ordered an ultrasound and he said I had a significant reduction in amniotic fluid, so he recommended induction.


LABOR AND BIRTH…

As inductions go, my labor was quite intense and painful. I was only 2 cm dilated when we began the suppositories and the doctor was hoping that 7-14 hrs later I would be at 10 cm and ready for Pitocin. He explained to me that he waits until women are fully dilated before he introduces the oxytocin because he feels that otherwise there is a much higher chance of the baby being in distress and labor ending with an emergency cesarean. He knew that I wanted to avoid this as much as possible, so we were going to go shway shway. As much as I had wanted to have a natural labor, I was afraid for my baby and decided to follow the recommendations.

After 25 hours of labor, my doula and husband encouraged me to take an epidural. They said I needed to find a way to rest since I was still only at 4 cm and I needed to save some energy for when it was time to push. I did not want to have an epidural but knew that they were right. I hadn’t been able to rest and I was miserable. I have a herniated disc and an extra vertebrae, so my back labor was really taking a toll on me. The epidural - as much as I had wanted to avoid it - saved me. It allowed me to gather my strength and enjoy the rest of my labor.

My son was born after 36 hours. It took two pushes and he was here. I was ready for “The Golden Hour” of skin-to-skin with him, yet before I knew it, he was taken to the NICU because he wasn’t breathing properly. I was heartbroken.

My husband went with our baby and I stayed behind with my doula, was stitched up, and was told I had to wait until the epidural wore off and I could walk before I could join my husband and baby.

One of my biggest fears was not being able to breastfeed and having the NICU nurses give my son formula. I was determined to be the first woman in my family to breastfeed and much of my research during pregnancy had focused on breastfeeding, so I felt ready to do what needed to be done and now my chance to do so was potentially being taken away from me.


FEEDING MY BABY… 

Three hours later, I was finally reunited with my husband and baby. Luckily, he was fine and healthy, albeit small (he only weighed 5 lbs 7 ounces). I immediately attempted to nurse him, held him skin-to-skin under a towel, but he wouldn’t latch correctly.

My doula tried helping us but we just could not manage a proper latch. He would nurse for a couple of minutes and then stop. I had an array of nurses with different tips and techniques come in and try to help, but we were not able to make it work. One nurse brought in a pump, the other tried getting colostrum out with a syringe (the most painful moment yet), another tried manual expression and spoon feeding, and others were ambivalent. I felt so alone and helpless, and I felt like a sore failure.

My doula called the local La Leche League and one of the leaders came to the hospital to see us. She was the sweetest lady, an Emirati, who had made the trip to the hospital in the heat during a time in which people do not usually leave their homes. It was the holy month of Ramadan, when Muslims all over the world fast from sunrise to sunset, so they tend to stay indoors and avoid the 120-130 degree heat. She taught me how to use nipple shields and how to “sandwich” my nipples so my son could get a grasp since she determined I had flat nipples. We tried a few times but we were still only partially successful and my son never stayed latched for longer than five minutes.

We went home the next day. The first few days at home were a blur to me. I remember trying, day and night, to nurse. I remember waking my son up to feed him, keeping a log of any drop that he ingested as well as counting his wet diapers. Things were not improving and there were no IBCLCs available in the whole city since everyone had left on vacation for Ramadan/summer.

Finally, I broke down and called my doula for help. She came over and immediately told me that my baby was jaundiced and it was now prudent to temporarily supplement him with some formula until we got things under control. She felt that the combination of my large breasts, flat nipples, and my tiny baby’s mouth gape, made us anatomically incompatible, and that it could correct itself as he grew.

Two days later, we ended up in the emergency room with a baby so jaundiced that he just could not wake up.  After we were dismissed, my husband bought our first tub of formula and bottles.

I knew my milk supply would suffer, so I began searching for a hospital-grade pump I could rent and use in the meantime. We contacted a woman in Sharjah, another Emirate (or State) about two hours away, the one lady available to rent us a pump. Apparently, in all of Abu Dhabi, there is not a single hospital-grade pump available for rent! I was so grateful for a local breastfeeding support page that gave me this person’s contact information.

My son quickly gained his weight back. I was pumping every 2-3 hours, day and night, but never got more than 2 oz. total from a session. I would still try to latch him on unsuccessfully, and I was topping him off with formula. He was still consuming mostly breastmilk, but I was starting to worry about my ability to pump enough milk for him as his appetite increased.

The same online breastfeeding support group recommended I take my son to a specialist in Dubai- yet another emirate- to evaluate why he couldn’t latch properly. The doctor was out of the country, like everyone else, so we had to wait until my son was six weeks old to see her. Shway, shway, once again.

The specialist diagnosed a pretty severe tongue tie and lip tie and was able to clip the tongue tie right there in her office. Hours later, my son was finally breastfeeding for the first time!

The first couple of weeks thereafter remained a bit tricky for us; I had to perform tongue stretches at every feed to avoid the reappearance of the tongue tie, and I had to practice how to hold and nurse my son. I was afraid of nipple confusion but I think it helped that we never used pacifiers and that I kept offering the breast before giving him bottles. I felt as if we were both learning and working hard together toward the same goal. It only took a few days for me to stop the formula altogether, and then the pumping. After having had to deal with both worlds - the breastfeeding world and the world of bottles, pumps, and formula - I marveled at how “easy” it was to just lift my shirt and feed my little guy on demand.

Since then, we’ve had a few other hiccups in our breastfeeding relationship- oversupply, undersupply, biting, cracked nipples, thrush, and I have had the worse acne of my life since giving birth- but my son is now 12 months old and I hope to continue nursing him until he self-weans.


PATIENCE PAID OFF…

Parenting-related things have not come easily to me: getting pregnant took a long time, my labor was one of the longest ones I have ever heard of, and I was not able to breastfeed my son for the first six weeks of his life. However, I did get pregnant naturally, I did have a natural delivery, and my boy is a healthy and happy, breastfed baby.

In the end, I got it all, I just had to learn to “shway, shway” and be flexible.


WHERE IN THE WORLD…? – A Closer Look

A lot of people have a very equivocal idea of what the United Arab Emirates are like. People whom I considered cultured and educated would ask me the dumbest questions upon finding out that I was planning on moving to Abu Dhabi. “Do you have to wear a burka?” is one of my favorites. Burkas are worn in Afghanistan only; besides, the UAE is quite liberal for being a Gulf Country (Bahrain, Kuwait, Qatar, Oman, Saudi Arabia, UAE). While it is an Islamic nation, religious freedom exists and there are plenty of Catholic churches, evangelical Christian churches, etc. People are free to practice their religion as long as they are not proselytizing. That being said, women are not required to cover with a shayla (head scarf) or anything else. There is, however, an expected code of decency when it comes to our clothes. Out of respect (not out of threat or fear), non-Muslims are asked to wear modest clothing: t-shirts are OK, skirts are OK, shorts are OK, just nothing too short, see-through, or revealing. It really isn’t that hard to do to show some respect.

One of the best aspects of living in Abu Dhabi is the true, raw multiculturalism. I remember how in the U.S., some of my friends called me “exotic” (I HATE that term) because I am half Mexican and half German and wasn’t born in the U.S. It was always a bit awkward to either be praised or be discriminated against for something that I had no control of, just the coincidence of where my parents happen to be from and what languages we speak. Here, I am nothing special and I love it.

A vast number of my friends here are also bicultural and married outside of their culture. My current friendship group can discuss the difficulties of incorporating three languages into our children’s lives without sounding like pretentious pricks. People in Abu Dhabi come from all over the world, and we all live in the same city but on parallel planes. In fact, the number of expatriates is so high that eighty percent of the people in the UAE are foreigners!

The biggest group consists of males from India, Pakistan, Sri Lanka, and Bangladesh, who usually come here to work in the ever-growing construction business or as taxi drivers. Another really large group of expats comes from the Philippines and Indonesia- these expats tend to work as restaurant servers, cashiers, nannies, etc. Many security guards, janitors and school custodians are Sudanese or Ethiopian. Professionals are mostly from Europe, North America, South Africa, Australia and New Zealand, and other Arabic-language countries (Lebanon, Morocco, Syria, Egypt, Jordan, etc.). The Emiratis also hold professional jobs and definitely occupy most leadership positions.

Sadly, each one of these groups has its own world and there is generally not a lot of crossover in friendships and recreation outside of it. We all communicate in English with one another to the extent that speaking English here is far more important than speaking Arabic. Luckily for us, most street signs, addresses, product labels, etc. are always written in both.

Birth

In this world of parallel universes, everyone lives and follows her own cultural practices as much as possible. This applies to everything from clothes to food (yes, non-Muslims can buy liquor and pork here) to pregnancy and birth.

Emiratis, up until recently, were used to giving birth at home with (not formally trained) community midwives and doulas, yet the country now has laws that state that all births should happen at hospitals so there is an accurate and legal count of all populations. I have heard of homebirths here, but it is illegal for midwives to practice outside of hospitals, so these births did not have professional assistance. To my husband and me, a homebirth without a midwife that could potentially get us into legal trouble was not an option.

Luckily, in our circle of expats there were many recommendations of a particular doctor who speaks English fluently and respects and understands a lot of birth preferences Western women often have, so I went with him and I was not disappointed. He accepted my birth plan (which, of course, was nothing like the actual birth, but I appreciated the intention to stick with it as much as possible). He also allowed me to have a doula despite the hospital’s policy to only allow one person in the delivery room, and he let me decide what I wanted or did not want the staff to do with my baby after delivery.

My doula is from the UK and I know there are several others in the United Arab Emirates, but most of them are used by expats in my situation who give birth here and often have no family members present to support them. Many of the Arab women usually have their mothers, friends, sisters, etc. in the room instead.

Women who are passionate about natural births, breastfeeding, babywearing, attachment parenting, placenta encapsulation, organic cooking and the like, have their own community and network here, and I was fortunate enough to tap into it ahead of time through a couple of Facebook groups. While we are a minority, we have enough numbers to be able to support each other and find ways to live, eat, and birth according to our principles.

Parental roles

Childrearing is another aspect that divides all the immigrants here. Every culture has their own beliefs and wisdom, and often they directly contradict another culture’s practices. It is quite difficult to generalize with such a diverse population, but it seems as though men and women have very different roles in their children’s lives when I compare American and Arab friends.

For example, one pretty much only sees Westerners and some Asians wearing their babies, especially the men. Also, from what my Arab friends tell me, husbands usually are not the ones changing diapers. They do, however, take charge in pushing strollers, carrying babies when they are out, or buying groceries for the family. How these practices unfold is often linked to how traditional vs. liberal each couple is.

It is important to note that just because men may not be the ones changing a diaper, for example, it does not mean that the bulk of the work is left to the women alone. In fact, Emirati women have huge support networks within their families and tribes, as well as hired help, so they always have plenty of people available for support.

An Emirati friend told me that the forty days immediately after giving birth, women here do nothing other than “rest, look beautiful, and breastfeed.” She says women wear expensive nightgowns and recuperate in bed with perfect make-up and flawless hair while they receive visitors who help care for the newborns. This scenario is the exact opposite of the Western experience where even taking showers becomes rare luxury.

One of my favorite things about Arab culture is that men are very affectionate and caring with kids. In my experience, men here constantly smile at my son, ask me his name and age, sometimes even pick him up or play with him when we’re in the elevator or in line at the store… in the U.S. it is generally the women who pay attention to other people’s babies, not the men. Perhaps this stems from the fact that Muslim families tend to be quite large and children are always seen as a blessing. For this reason, Abu Dhabi is truly one of the most baby-friendly places I have ever visited, and it is also incredibly safe. We are fortunate to be parents here.

Breastfeeding vs. Formula

While not all women breastfeed, it is highly encouraged by everyone, not just because of the benefits for moms and babies, but also religiously. The Qur’an, the Muslim holy text, specifically states that all babies have a right to be breastfed for at least two years, so Arabic societies are not hostile toward this practice in any way.

Most malls have nursing rooms, some incredibly luxurious, equipped with everything from leather sofas to playpens for older kids to spend time in while younger ones are fed. Another option for privacy is making use of the prayer room for breastfeeding. Virtually every business, no matter its size, has separate prayer rooms for men and women so Muslims have a place to worship when it is time to do so. Muslims pray five times a day at set times, so it is great to have places available everywhere. Using these facilities for breastfeeding is open to women of all faiths.

Local women wear long, black dresses over their clothes called abayas, and they actually makes some nursing-friendly abayas here that have little concealed “windows” that allow women to access their breasts without having to take the whole abaya off in public. I have seen niqabis, women who cover everything but their eyes, nursing this way in public, even with males present.

Nursing is legal everywhere and covers are not compulsory. I never use a cover but I do try to be discreet and use a nursing tank top under my shirts. I can honestly say that I have never had anyone stare at me or say anything to me while nursing my son, and I have nursed in all kinds of places this last year. It seems far less of an issue than it does in the West, where ironically women consider themselves liberated yet often aren’t free to even feed their children without harassment.

There is definitely a lot of formula available for people who do not breastfeed, but at the hospital I was never offered any formula or given any samples and instead I was encouraged to breastfeed my baby. I wish, however, there would be more trained staff, like IBCLCs, since these seem to be far and in between and people like me who have a tough time breastfeeding do not have as much help available to them as they should. Additionally, having more pumps and education could help out the women who are too embarrassed or prefer not to feed in public so they have an alternative to supplementing with formula.

Depending on the healthcare professionals’ training, advice can often be outdated (i.e. give cereal at four months, feed on a schedule, etc.), so it is important to make information and education available to all women giving birth here and in all languages.

Currently, there are several initiatives within the country to help promote and protect breastfeeding. World Breastfeeding Week inspired many articles and news stories in the country, so I am hopeful that more and more women will chose what is best for their babies and have the help they need to do so.”

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