Wet nursing for refugee orphans in Bangladesh

By Yara Sfeir, UNHCR Bangladesh

Yara Sfeir is an International United Nations Volunteer posted as a Nutrition Coordinator for the two Rohingya refugee camps of Nayapara and Kutupalong on the border of Myanmar in Bangladesh.

The opinions expressed are those of the author and cannot be attributed to UNHCR.

This article shares the practical realities of identifying wet nurses for young orphans where artificial feeding was not considered an acceptable, feasible, affordable, sustainable and safe option.

UNHCR started working in Bangladesh in 1992 upon the invitation of the Government of Bangladesh to assist in the repatriation of more than 250,000 Rohingya refugees. These people had fled from Myanmar during the same year due to socio-economic and political reasons. UNHCR has since assisted in the repatriation of around 230,000 refugees, equivalent to 95% of the original registered refugee caseload.

As of end December 2007, there were some 27,400 refugees residing in the two camps of Kutupalong and Nayapara situated along the Bangladesh-Myanmar border. UNHCR provides care and maintenance while actively pursuing durable solutions for the remaining refugees¹. The Ministry of Health along with one local non-governmental organisation (NGO), Technical Assistant Inc (TAI), were the only two UNHCR implementing partners until recently. In November 2007, Research Training Management International and Handicap International began working in the two camps. In both camps², Medecins Sans Frontieres- Holland has been present and is planning to close down its operation in 2008.

In the Rohingya refugee camps of Nayapara and Kutupalong in Bangladesh, three types of nutrition programmes are operating, in addition to the World Food Programme (WFP) general food distribution.

• A Blanket Feeding Programme (BFP) for all children between 6 and 24 months residing in the camps
• A Supplementary Feeding Programme (SFP) for pregnant or lactating mothers and moderately malnourished children between 6 to 59 months. A total of three SFPs are operating between the two camps.
• A Therapeutic Feeding Centre (TFC) for severely malnourished children from 6 to 59 months. One TFC is present in each camp, run by the MOH.

The challenge

In October 2007, Ministry of Health staff working in the TFC alerted the UNHCR team managing the camps that five orphans below six months of age had been brought by caretakers to the TFC but were sent home again since no guidelines were set for their care. No infant formula is provided in the camps and the caretakers were feeding the infants with cereals. At first the UNHCR team thought about providing infant formula for the orphans. However, after consulting the 'UNHCR Policy Related to the Acceptance, Distribution and Use of Milk products in Refugee settings (2006)³, and discussions with the UNHCR Headquarters Nutrition Unit, the challenges of introducing infant formula to such an unhygienic setting were recognised. Furthermore, the caretakers were illiterate and unable to read written guidelines. Another fear was that all mothers would start requesting infant formula for their infants, as it was common practice for distributed food to be sold in the camps.

The options

We therefore opted to find a 'wet nurse' - a woman who is not the mother who would breastfeed the infant. This strategy is included in the options outlined in the Operational Guidance on Infant and Young Child Feeding in Emergencies (2007)⁴ produced by the IFE Core Group, of which UNHCR is a member. We realised that the HIV status of the wet nurse should be considered. However, in the Nayapara and Kutupalong camps the risk of HIV was considered to be low⁵, therefore the wet nurses were not offered Voluntary and Confidential Counselling and Testing for HIV⁶.

In Nayapara TFC, the first wet nurse was the baby's aunt

In the Nayapara camp there was a mother who was already breastfeeding one orphan who was not a relative. She was also breastfeeding her one year old child at the same time. Since this seemed to be an accepted practice in the community, we asked the Community Health Worker (CHW) and the TFC and SFP staff, as well as the caretaker, to actively look for wet nurses amongst the relatives of orphans. In the event that no relative was lactating, we urged them to extend their search to the wider community. As an incentive, we agreed to offer the wet nurses food from the SFP. After a few days, one wet nurse was found for one orphan: she was the orphan's aunt. It had not occurred to her that she could also breastfeed her orphan nephew. "It is an honour to breastfeed my nephew" said the aunt smiling, hugging the baby and cuddling him. This positive experience encouraged us further.

The CHW and selective feeding programme staff informed us that no other wet nurse could be found so we decided to reach out to the community. One of the ways in which we did this was to talk with groups of pregnant and lactating women when they came to the SFP for food. We told them, "We are the team responsible for nutrition in the camps. We are facing a problem. We need your help. We have orphans in our camps that are too small to be given food. They should only be breastfed. We don't want to give them powdered formula because if the water in the formula is not clean, they will be sick and have diarrhoea. Would you or someone you know be able to breastfeed the orphan?" We explained that the baby already has a caretaker and that their role would only be to breastfeed the baby several times a day. We also explained that the wet nurse would receive an extra food ration from the SFP (an egg, a banana and some porridge) every day. Two lactating mothers agreed on the spot. One of them was hesitant but when we took her to see the orphan her doubts disappeared. We asked the wet nurses to come to the centre every day. The TFC staff and the caretaker would make sure the wet nurse was breastfeeding the infant 8 times a day and that she also received her extra ration. In the Kutupalong camp, a wet nurse was easily located for one orphan and she breastfed him more than 6 times a day, in the morning and the afternoon. This was also a very encouraging outcome.

However, a number of difficulties did arise. One wet nurse was not allowed by her husband to breastfeed an unknown child, so we had to actively locate and recruit another woman for this child. Luckily, we were able to find another willing wet nurse, although she found it difficult to breastfeed 8 times a day since she lived far from the centre. Since the TFC closes at 2pm, we asked the caretaker to take the infant to the wet nurse every afternoon. This seemed to work well for all the orphans. However, another problem soon arose. As refugee women do not feel safe travelling at night, the caretakers were asking for infant formula for night-feeds. During a training on breastfeeding organised by UNHCR, a solution was found through discussion and brainstorming led by a trainer from the Bangladesh Breastfeeding Foundation. The wet nurse would hand over expressed breastmilk to the caretaker who would keep it in a container. If the milk needed to be kept for more than 6 to 8 hours, then a box of ice would be given to the caretaker for storing the expressed milk. The milk could then be heated and given to the infant by cup. This practice is now adopted in the camps.

Of course, a number of challenges remain. For example, there was an occasion when a caretaker decided that when her orphan had a bout of diarrhoea that this was due to the wet nurse's breastmilk. She therefore bought powdered milk. On showing it to us it was clear that she was unable to read the warning that clearly stated "not suitable for infants below 1 year"! We discussed the issues around this with her and offered advice. However, she seemed uninterested and never came back to the TFC. Challenges like these are, of course, to be expected but in my opinion, the advantages of wet nursing outweigh the problems faced. The best results for malnourished orphans have so far consistently been when the caretaker is also the wet nurse.

For more information, contact: Yara, Sfeir, email: SFEIR@unhcr.org

An UNHCR Guidance on Infant feeding and HIV in Emergencies for Refugees and Displaced populations is being finalised. The purpose of the guidance is to assist UNHCR, its implementing and operational partners and governments on policies and decision-making strategies on infant feeding and HIV in emergency situations. For further information, contact: Fathia Abdallah, UNHCR, email: Abdallah@unhcr.org

Ann Burton, Senior HIV Asian Regional Officer, Bangkok, UNHCR. Marian Schilperoord, Senior HIV Technical Officer, Geneva, UNHCR. Paul Spiegel, Chief of Public Health and HIV Section, Geneva, UNHCR.

Bangladesh is experiencing a low level HIV epidemic. In particular, the level of HIV infection in southern Bangladesh where the refugees are located is extremely low. Notably , the 7th and latest round of sentinel surveillance in the first half of 2006 did not detect any HIV infection in sex workers (an most-at-risk population) in southern Bangladesh bordering Myanmar where the camps are located1. Though Myanmar is experiencing a generalised epidemic, the geographical pattern is heterogeneous and available evidence indicates that northern Rakhine State (the area of origin of the refugees) is experiencing a low level epidemic. Moreover, this is a long-term refugee situation and HIV prevalence in the refugees is more likely to approximate that of the host community. Thus, in the Nayapara and Kutupalong camps, the risk of HIV is considered to be very, very low.

UNHCR's policy, following international guidelines, is that the first option should be replacement feeding where this is acceptable, feasible, affordable, sustainable and safe (AFASS), Where this is not available, wet nursing should only be considered in women known to be HIV negative and include HIV awareness and counselling support to the breastfeeding women (and her partner) to stay HIV negative. Thus, voluntary and confidential counseling and testing (VCCT) is required before wet nursing begins and thereafter on a periodic basis to ensure that the wet nurse remains negative.

HIV services in the surrounding host community are in the early stages of implementation; the nearest HIV VCCT centre is in Chittagong, a 4-5 hour journey one way. Though far from ideal, due to the extremely low risk and the considerable operational constraints, it was determined at the country level that the risks of not breastfeeding in this context were far greater than those posed by the risks of not offering HIV testing. However, after consultation within and outside of UNHCR, UNHCR will work with its implementing and operational partners to ensure that before potential wet nurses begin to breastfeed infants, they are HIV negative. This will require the provision of VCCT.

¹http://www.icddrb.org/activity.htm Accessed 20th January 2008