Infant Formula Distribution in Northern Iraq

Mother breastfeeding, Northern Iraq, 2003

Summary of assessment¹

Between 19th June and 12th July, 2003, a nutrition and mother and child health assessment was carried out in Northern Iraq (NI), commissioned by Caritas Austria and Cordaid Netherlands. Focusing on the needs of those in the Kirkuk and Mosul areas (both internally displaced people (IDP) and returnees), the objectives of the consultancy included an assessment of the situation of the local hospitals and the health centres in terms of coverage and treatment of malnourished children, and an estimation of the impact of the cessation of the Oil for Food (OFF)² programme on the malnourished. The investigations were based on a collection of qualitative and quantitative data, including epidemiological health and nutrition indicators (where available), institution- derived data and qualitative information from interviews with staff and beneficiaries. This summary focuses on the observations and concerns regarding the inclusion of infant formula in the general food ration.

Oil for food (OFF)

Since 1996, the World Food Programme (WFP) has been responsible for the distribution of food aid to the northern regions, as provided by the Government of Iraq (GOI) under UNSCR 986 distribution plans. The significant improvements in both chronic and acute malnutrition in NI since 1996 can be related to the cumulative effect of improved household food security (continuous distribution of food rations via OFF), implementation of an OFF-associated targeted nutrition programme (TNP), increased health inputs and improved local economy.

The current distribution of the general ration is scheduled to continue until November 22,2003³. One general ration supplies about 2200 kcal per person per day and is usually distributed on a monthly basis (a 3-monthly food ration was distributed before the war started). For the last trimester of pregnancy and the first four months after delivery, a woman receives an additional ration of 1 kg sugar (from WFP)⁴ and High Protein Biscuits (from UNICEF). A family with an infant below 1 year of age receives an additional ration of 3.6kg infant formula (8 tins per month), 0.9 kg complementary infant food, 1 bar of soap and 0.5kg detergents.

Infant formula distribution

Since 1997, the distribution of infant formula in NI has increased from 1.8 kg to 3.6 kg per month. A recent survey in NI found a high percentage of bottle-fed infants (64%), ranging from 51% (0-2 months) to 69% (9-11 months), and representing a 25-30% increase since August 1996⁵. Correspondingly, exclusive breastfeeding rates were low, at 7% for infants aged 0-6 months. Between 6 and 9 months, just over half (53.4%) of infants received complementary food in addition to breastfeeding, despite their inclusion in the ration (currently 0.9 kg/month). The most commonly reported health problems were diarrhoea and acute respiratory infections⁶.

According to information from beneficiaries, the current distribution system is inadequate. Infant formula No. 1 (suitable from birth to 6 months), No. 2 (follow-on formula, six months onwards) and Cerelac (a commercial weaning food) are given on a monthly basis to each infant during the first year of life, sometimes irrespective of his/her age⁷. The instructions on the infant formula are written in English and Arabic only and not in Kurdish language, even then 51% of the women in NI are illiterate. No acknowledgement or advice is given on the use of different formula by age - if mothers have no knowledge about this difference in the composition of breast milk substitutes, or have no possibility to exchange the tins with relatives or neighbours, infant feeding is very likely to be greatly inadequate.

The presence of infant formula in the food basket continues to discourage mothers from breastfeeding. In addition, it is frequently mixed with unclean water, available in limited quantities and handled under extremely hot conditions. Consequently, bottle-feeding coupled with inadequate water and sanitation facilities is a major contributing factor to infant malnutrition, morbidity and mortality, especially for those living in remote areas where there is limited access to medical facilities.

Returnees in a rural area of Dibaga sub-district in Erbil governorate, Northern Iraq, 2003

Reports of health institutions suggested an association between severe malnutrition among infants and the high prevalence of bottle-feeding in NI. For example, in Erbil governorate, 44.7% of severely malnourished admissions were below the age of 6 months, of whom none were exclusively breastfed, nearly one-third (30.7%) of the infants were exclusively bottle-fed and 69.3% recieved mixed feeding (bottle and breastfeeding)⁸. Furthermore, institutional based data and visits to four different paediatric wards revealed several limitations in the management of severe malnutrition. These included lack of therapeutic milk and modified oral rehydration solution during the initial stage of treatment and lack of awareness about the importance of a rehabilitation phase. Education on infant feeding practice was also lacking. During visits by the assessor, mainly undiluted ORS - sometimes mixed with therapeutic milk - was offered by feeding bottles for severely malnourished children with diarrhoea. Mothers continued to offer mixed or bottle- feeding during their stay in the hospital as they did before admission. Many of the mothers with children admitted in paediatric wards believed that they did not have enough breast milk. A UNICEF study in NI (2002)⁹ revealed that 51.1% of doctors and health staff have not yet heard about the concept of exclusive breastfeeding.

Recommendations

The following recommendations were made as a result of the assessment:

The untargeted distribution of infant formula is inappropriate. Strategies to protect and support breastfeeding are urgently required. Breast milk substitutes should only be distributed to infants where the individual need is specifically established. The current system is, undoubtedly, contributing to infant morbidity and malnutrition rates, in a region ill equipped to deal with the consequences.

Worryingly, plans to meet infant feeding needs after November 2003 are not confirmed. A new food distribution system, targeting vulnerable groups according to predefined social/health and nutrition-related criteria such as young children, pregnant and breastfeeding mothers, elderly and disabled people is needed, rather than a blanket distribution of food to the whole population.

Training of medical personnel is urgently needed in promotion of exclusive breastfeeding and the management of severe malnutrition.

For further information, contact: Dr. Veronika Scherbaum, email: scherbau@uni-hohenheim.de, or Mrs. Sabine Wartha, Caritas Austria, email: S.Wartha@caritas-austria.at, or Geke Verspui, Cordaid, email: Geke.Verspui@cordaid.nl

By the World Food Programme (WFP)

Given the considerable reference to WFP activities in this assessment, WFP were invited to offer their perspective.

There are a number of points which the WFP would like to raise, in light of the assessment findings from Iraq. Under the oil for food (OFF) programme, the Ministry of Trade (MOT) has been responsible for procurement of all food commodities including infant formula. WFP is responsible for the distribution in Northern Iraq only and not in the centre and the south. Following the war in 2003, WFP is facilitating the procurement of all commodities already negotiated by the MOT.

With regard to targeting infant formula I and II by age, this issue was also raised by the WFP and United Nations Office of the Humanitarian Coordinator for Iraq (UNOHCI) food observers in 1997/98, when the Government of Iraq was responsible for procuring and distributing the food ration. As part of WFP's observation mandate, WFP analysed the nutrient contents of formula-I and formula-II distributed in Iraq in 1998 (over 60 brands) and did not find significant difference in contents of the two formulas. Following a request for advice posted on Ngonut¹⁰, personal communication from two nutritionists/professors suggested the differences reflected marketing stunts rather than any real difference in nutrient profile. WFP, therefore, saw no reason to advocate for pursuance of the expensive, and almost impossible, task of identifying infants below and above 6 months of age and then plan, procure, transport, and distribute different milks to such a large, and changing, population on a monthly basis.

Breast milk substitutes should only be distributed to infants where the individual need is specifically established - this is internationally agreed upon policy. Despite WFPs consistent advice against the blanket distribution, the MOT has not agreed to exclude infant formula from the general ration. This is to avoid any disquiet that is likely to occur when an established ration is reduced/modified in the prevailing political situation in Iraq, especially given the discontent shown in 1996 when infant formula was removed from the ration by the government. At present, UNICEF is trying to develop a strategy for targeted distribution, in collaboration with the Ministry of Health and Ministry of Trade.

Regarding plans for after November 2003, WFP is mandated by the UN resolution to take the responsibility of Public Distribution System of Food until November. After that it becomes the responsibility of the Coalition Provisional Administration (CPA) whose plans are not yet available.

¹Final Report, Nutrition/Mother and Child Health Consultancy in Northern Iraq, 19/6 - 12/7/2003, Dr. Veronika Scherbaum, on behalf of Caritas Austria and Cordaid Netherlands.

²A Memorandum of Understanding (MOU) was signed in 1996 between the United Nations (UN) and the Government of Iraq (GOI). The UN Security Council Resolution (SCR 986) permitted the GOI the export of $2 billion of petroleum every 6 months and the use of the revenues to import items related to basic humanitarian needs of the population.

³Source: WFP nutritionist in Suleimanyiah, Northern Iraq

⁴At the time of the assessment, WFP provided 1kg sugar and 4kg of oil (substituted with pulses when oil not available) to this group. This ration has since been revised to 2kg oil, 1.02kg cheese, 1kg milk (18 September 2003).

⁵UNICEF, 1996 multiple indicator cluster survey - Iraq, results from Northern governorates.

⁶UNICEF-Northern Iraq and the Regional Ministries of Health & Social Affairs. Nutritional status of children in autonomous Northern Governorates (Dohuk, Erbil and Suleimanyiah) of Iraq, data collected November 2002, report 23 March 2003.

⁷The ration scale of infant formula (3.6 kg per month) was planned by the Iraqi Trade ministry, and is not a standard scale of the WFP programme. Source: WFP Nutritionist, Suleimanyiah, Northern Iraq.

⁸Directorate of Health data from Erbil Nutrition Rehabilitation Centre, n=144, Jan to March, 2003.

⁹UNICEF-Northern Iraq (2002) KAP survey on exclusive breastfeeding among doctors and health staff.

¹⁰Ngonut was a forum of email exchange between nutritionists, since replaced by Nutritionnet (www.nutritionnet.net)