Letter on infant feeding in Former Yugoslavia, by Fiona Watson, Aileen Robertson and Aida Filipovic

Dear Editors,

We would like to comment on the article "Infant Feeding in Emergencies: Experience from Former Yugoslavia" (Field Exchange, Issue 1, May '97). Our experiences differ with those of the author. We feel the piece left the reader with the false impression that little attention was paid to breastfeeding during the emergency in the former Yugoslavia and implied that infant formula was distributed by humanitarian agencies because no alternative strategy was offered. Our experience does not accord with either of these views.

Contrary to the authors impression that there was a dearth of sound data on infant feeding practices, large representative child health and nutrition surveys were carried out by UNICEF and WHO, with assistance from ACF. These surveys were carried out in four besieged areas of Bosnia (Sarajevo, Tuzla, Zenica and Bihac) and in the Krajina (part of Croatia occupied by Serbs at that time and the scene of some of the worst atrocities of the war) in the summer and autumn of 1993 when the conflict and confusion were at their height.

The surveys showed that between 2 and 11 per cent of mothers with babies under 4 months of age were exclusively breast feeding and that the early introduction of sugared water, tea, or other liquids including cow's milk was commonly practised (Robertson et al, 1995; Robertson & James, 1996). Furthermore, babies were frequently separated from their mothers immediately after birth in hospital and swaddled thus hampering the initiation of successful breast feeding.

Data on breast feeding rates and practices were therefore available early on in the war and were widely disseminated to government and international agencies, including NGOs.

The article correctly points out that many doctors believed that mothers were unable to breast feed because the stress of war stopped their milk production or that mothers were too undernourished to produce milk. For this reason, UNICEF and WHO in co-operation with the Ministries of Health targeted health personnel in the first instance. A large number of training seminars were implemented throughout Bosnia and in other parts of the former Yugoslavia, again with assistance from ACF, starting in 1993, to promote breast feeding. Initially these seminars were led by international breast feeding experts (e.g. midwife Chloe Fisher from Oxford) who were willing to come to the former Yugoslavia despite the continuation of war. National trainers then continued to arrange and implement seminars. The promotional campaign was successful in heightening awareness about the benefits of breast feeding and on changing the attitudes and practices of health workers. There is some evidence that breast feeding levels increased as a result (Robertson & James, 1996).

In order to ensure the sustainability of the initiative, UNICEF and WHO began to work with local health professionals to develop national policies on infant feeding. A number of health personnel were sent on breast feeding courses outside the country so that they could continue with the promotional effort. Leaflets and posters were developed by WHO and UNICEF, translated into the local language, published, and disseminated through health services and by many humanitarian agencies.

At the same time UNICEF, WHO, WFP and UNHCR developed a joint statement on infant feeding and distribution of infant formula during the emergency which highlighted the importance of breast feeding in conditions where hygiene is compromised and infant formula supply is uncertain. This statement recommended that the amount of infant formula distributed as aid should be severely limited (it was assumed that only 5 per cent of mothers could not breast feed at all and therefore required formula). As a result of the statement, a decision by all humanitarian relief organisations (including NGOs) to discontinue mass distribution of infant formula was taken and mass distribution stopped in January 1995.

There is no evidence that babies died because there was a shortage of infant formula during the war in the former Yugoslavia. Rather the issue was how to change attitudes about infant feeding among health professionals and some humanitarian agencies - particularly those whose first emergency experience was in the former Yugoslavia. Ironically, an opportunity to promote public health through reversing the pre-war trend of bottle feeding arose in the former Yugoslavia, as a result of the emergency. We feel that the said article missed an opportunity to illustrate this potential for beneficial change which in rare cases can occur in the midst of the misery of an emergency.

Yours etc., Fiona Watson, Research Fellow, Centre for International Child Health, Institute of Child Health.
Aileen Robertson, Acting Regional Advisor for Nutrition, WHO Regional Office for Europe, Copenhagen.
Aida Filipovic, Nutrition Advisor, Institute of Public Health, Sarajevo.

Robertson A, Fronczak N, Jaganjac N, Hailey P, Copeland P, Duprat M.Nutrition and immunisation survey of Bosnian women and children during 1993. Int. J. Epi. 1995; 24: 1163-1170. Robertson A, James WPT. War in the former Yugoslavia: coping with nutritional issues. In: Introduction to Human Nutrition. J.I. Mann (ed). O.U.P. 1996.