Infant Feeding in Emergencies: Experiences from Former Yugoslavia

Anne Walsh - Health Adviser, Children's Aid Direct.

War in the former Yugoslavia presented a relatively new situation to the international aid community whose prior emergency experience had mostly been in less developed countries. This was a European country which endured intense civil war leading to massive displacement of people. Food supplies suffered severe interruptions or complete stoppages for long periods and large numbers of people became increasingly impoverished due to sale of assets and virtual siege conditions in large towns.

Yugoslavia had a highly educated population with extremely developed health and education services. These services managed to continue in some fashion during the war in spite of seriously depleted resources. Many professionals left the country during this period although there were some who stayed with their communities. The humanitarian response came from all segments of the international community: the UN, major donors, established NGOs, new NGOs and even concerned individuals or community groups.

In the field of infant feeding there were many issues to address, and few or no standard or established practices in dealing with them, that were felt to be appropriate to a European culture. A need for specialist foods for infants was often expressed by national doctors and other health workers, local authorities and individual mothers themselves.

The humanitarian community, at all levels including the UN and ECHO, responded to those expressed needs by sending 'infant formula' and 'weaning foods'.

Since May 1995 I have been in close contact with field workers implementing our programmes on the ground in former Yugoslavia. Our programmes included food and hygiene item distribution and Mother and Child Health (MCH) centre support. By talking to our staff and through my own analysis of the situation it is obvious that there are a number of recurring problems and issues around infant feeding in this type of situation which the relief community needs to recognise and address.

Some of the issues:

A bottle-feeding culture
Local medical staff stated that 70% of women could not breastfeed and that infants were dying because there was no infant formula milk available. Yugoslavia was known to have a predominantly bottle-feeding culture. Furthermore, wet nursing was or is not practised.

Due to the complexity of the war, the number of factions fighting at various times and the continuously changing hands of territories, sound data on infant feeding practices became lost or unavailable. Security and staffing were not conducive to new data collection and surveys to assess the real extent of the problem.

National or international breastfeeding specialists were not available to advise field staff. As aresult of this, field staff often saw no alternative but to answer the pleas of health professionals and mothers by distributing infant formula.

The benefits of breastmilk and breastfeeding were either not sufficiently understood or given enough credence for field workers and other health staff to make the additional efforts required to promote breastfeeding.

Training
Many aid workers lacked experience or technical training in emergency work or knowledge of appropriate maternal and child care practices. Untrained aid workers were oblivious to there being important issues involved in infant feeding - especially in an emergency context. Others were aware of the issues but had no answers to the problems they were faced with other than to supply infant formula foods to prevent further suffering. As a result, many questionable beliefs and practices were in evidence.

The belief that stress prevents a mother from breastfeeding was innate and reinforced by families and health professionals. If a mother felt that stress was preventing her from breastfeeding, the only known solution was to supply breastmilk substitute.

Health worker training in Yugoslavia, as in many other European countries, did not focus on the benefits of breastmilk and ways to support mothers wishing to breastfeed. More often, training promoted the idea of the need to 'top-up' with breastmilk substitutes, or that it was good or even better for the baby to be bottle-fed.

Choice
Most aid workers believe strongly in the right of a woman to choose how to feed her child. They don't necessarily realise that an informed choice is difficult to achieve in normal circumstances. Getting information and then support for mothers during a war may be virtually impossible.

Field staff in former Yugoslavia acted in ways they felt were best to meet the needs of mothers and
infants during the war. Although mistakes were pointed out to them and some practices did improve e.g. more controlled methods for distribution of formula milk established, the critical problem of getting mothers to breastfeed when they believed that they were not capable of doing so could not be practically solved during this emergency. A field worker faced with a hungry infant and distressed mother does not have the time, even where there is knowledge or experience, to be able to give individual breastfeeding counselling and ongoing support. What they can do is give infant formula, with preparation instructions in local language, labelled without a brand name to avoid free advertising for formula companies. To refuse the provision of infant formula in these situations is sometimes a recommended strategy. However there is insufficient evidence to show that this approach would encourage the mother to return to or initiate breastfeeding.

The Next Crisis
Even now, following analysis of what happened in former Yugoslavia, we do not have clear practical guidelines on what to do in the future. Are we clear on what would be accepted as best practice for helping mothers to breastfeed their children? Do we have ways of informing the well meaning aid worker who might not have the understanding or training to deal with the conflict, between accepted best practice and practical constraints on the ground.

There is still a lot of debate, research, and documentation required in order to strengthen our infant feeding practices in emergencies. Practical and accessible guidelines that can be implemented in the face of a real emergency, in a culture not convinced of the benefits and robustness of breastfeeding, are urgently needed.