Ratiba Awad with her three children, Ouday (5), Ahraa (4) and Batoula (7 months), in the abandoned cow shed where they live with over 20 other Syrian refugees since having to flee their homes due to the war in Syria (Photo: Eoghan Rice / Trócaire)

Why breastfeeding mothers request and use donated infant formula

Special guest post for a series on Infant and Young Child Feeding In Emergencies

By Dr. Karleen Gribble

In emergencies donations and untargeted distributions of infant formula result in increased sickness and deaths of babies. This is because the donations and distributions result in infants that would otherwise be breastfed being fed infant formula. Many wonder why this is so. Surely breastfeeding women would continue breastfeeding and not feed formula to their babies unless they really have to? Unfortunately not, in an emergency breastfeeding women given formula will feed it to their babies and furthermore will request it from aid agencies.

Why? The desire of breastfeeding women to obtain infant formula in an emergency arises from a variety of circumstances.

Women believe they are unable to breastfeed

Women may believe that they are unable to breastfeed. The belief that stress or lack of food prevents milk production is common and is often based on mothers’ interpretation of their infants’ behaviour. While neither stress nor moderate malnutrition affects breast milk production or quality [1, 2], stress can delay the milk ejection reflex, resulting in infants becoming fussy at the breast. Mothers can interpret such fussiness as indicating that they do not have enough or good enough milk for their infants. Support can enable mothers to maintain exclusive and continued breastfeeding [3]. If a woman is severely malnourished, feeding the mother will enable her to feed her baby.

 

Screen shot 2016-01-15 at 10.44.23 AM
Photo: Courtesy of K. Gribble

 

Cultural beliefs

Cultural beliefs may result in requests for infant formula. For example, in Haiti after the 2010 earthquake some believed that the experience of trauma would make their breast milk bad [4]. Therefore mothers who were traumatised requested infant formula because they did not wish to harm their infant by breastfeeding. Similarly, in many cultures colostrum is considered unhealthy for newborns and women may seek infant formula to feed their babies until their milk “comes in.” Education and breastfeeding support can enable women to adapt their view of these situations, to exclusively breastfeed their young infants and continue to breastfeeding after the introduction of complementary foods [3, 4].

Aspiration to bottle feed

Aspiration to bottle feed may lead to women requesting infant formula. In the developing world, formula feeding is associated with high socio-economic status. Advertising suggesting that formula feeding improves brain function and educational success has impacted community beliefs about the desirability of formula feeding. When women become aware that aid organisations are distributing infant formula they may see this as an opportunity to provide their baby with something that they have always wanted to give them but have not been able to afford.

 

Screen shot 2016-01-15 at 10.45.19 AM
A mother in China is asking aid workers for milk for her 2 month old baby. (Photo: courtesy of K. Gribble)

Infant formula is a high value product

Mothers and other members of the community may seek infant formula, not to feed their own infant, but to sell. Infant formula is a high value product everywhere, but especially in the developing world. For example the cost of fully formula feeding an infant in the Philippines is estimated at more than three quarters of household income for those who are in the bottom 30% of household income earners [5, 6]. In the aftermath of an emergency obtaining something of high value provides some security. Individuals may also seemly be seeking to profit from the emergency in obtaining infant formula and fraudulent requests for formula are encouraged by the presence of excessive donations [e.g. 7].

Formula feeding is normal in the population

In some countries or locations formula feeding is the normal and expected way to feed a baby [8, 9]. When an emergency occurs, women may still desire to bottle feed. They may also be more comfortable with formula feeding than breastfeeding and wish to formula feed simply because it is familiar and therefore comfortingly normal. Being from a culture where bottle feeding is normal means that breastfeeding in public may be stigmatised. This presents a barrier to breastfeeding that is particularly evident in emergencies where privacy may be scarce.

People may ask, if the mother wants to formula feed, then why not support her decision regardless of her reasons, shouldn’t we be respecting her autonomy?

It’s a difficult situation.

The question must be asked, are women actually making an autonomous, informed decision to formula feed? Or is this decision based upon misinformation?

In a situation that is manifestly dangerous for formula feeding, where the likelihood of serious illness or death resulting from feeding formula is high, what is the responsibility of the aid organisation to the baby and to the mother?

And given the often enormous cost of supporting formula feeding in emergencies what is the responsibility of the aid organisation to donors who want value for money in their support and to other aid recipients who might miss out on aid because of resources being expended on supporting formula feeding infants that could be breastfed.

Answers to these questions are still being worked out and probably the response will vary depending upon the context. In the mean time, what is clear is that providing infant formula in emergencies is a wickedly tricky thing to do well and frustrating easy to do poorly.

What is certain is that a request for infant formula cannot be interpreted as meaning that formula is really needed or wanted.

Actors engaged in providing infant formula in emergencies need to be aware of these issues, they must be familiar with the the internationally recognised guidance [10, 11] and they must be very careful; for the potential for their good intentions to cause great harm is massive.

Adapted from Gribble, K. (2014). Formula feeding in emergencies. In V. R. Preedy, R. R. Watson & S. Zibadi (Eds.), Handbook of Dietary and Nutritional Aspects of Bottle Feeding (pp. 143-161). Wageningen. The Netherlands: Wageningen Academic Publishers.

References

  1. Prentice, A.M., et al., Dietary supplementation of lactating Gambian women. I. Effect on breast-milk volume and quality. Human Nutrition – Clinical Nutrition, 1983. 37(1): p. 53-64.
  2. Hill, P.D., et al., Psychological distress and milk volume in lactating mothers. Western Journal of Nursing Research, 2005. 27(6): p. 676-693.
  3. UNICEF. Calmness and love for displaced breast feeding mothers in the new temporary shelter. 2008; Available from: http://www.unicef.org/georgia/reallives_10695.html.
  4. Dörnemann, J. and A.H. Kelly, ‘It is me who eats, to nourish him’: a mixed-method study of breastfeeding in post-earthquake Haiti. Maternal and Child Nutrition, 2013. 9(1): p. 74-89.
  5. Republic of the Philippines, N.S.O. Families in the bottom 30 percent income group earned 62 thousand Pesos in 2009. 2011 1 June 2013]; Available from: http://www.census.gov.ph/content/families-bottom-30-percent-income-group-earned-62-thousand-pesos-2009-final-results-2009.
  6. UNICEF. The costs of formula feeding. 2005 1 June 2013]; Available from: http://www.unicef.org/philippines/downloads/infokit final.pdf.
  7. Whitehead, B. Bfing in an emergency. 2005 1 June 2013]; Available from: http://community.lsoft.com/scripts/wa-LSOFTDONATIONS.exe?A2=LACTNET;58401ddb.0505A.
  8. Nemeh Ahmad, A.-A., O. Abidhakeem, and A. Roba Tawfig, Factors associated with exclusive breastfeeding practices among mothers in Syria: A cross-sectional study. British Journal of Medicine and Medical Research, 2014. 4(14): p. 2713-2724.
  9. Lutter, C.K. and A.L. Morrow, Protection, promotion, and support and global trends in breastfeeding. Advances in Nutrition: An International Review Journal, 2013. 4(2): p. 213-219.
  10. IFE Core Group, Infant and Young Child Feeding in Emergencies: Operational Guidance for Emergency Relief Staff and Programme Managers. Version 2.1. 2007, Oxford: ENN.
  11. The Sphere Project, The Sphere Handbook: Humanitarian Charter and Minimum Standards in Disaster Response. 2011, Geneva: The Sphere Project.

Title photo: Ratiba Awad with her three children, Ouday (5), Ahraa (4) and Batoula (7 months), in the abandoned cow shed where they live with over 20 other Syrian refugees since having to flee their homes due to the war in Syria (Photo: Eoghan Rice / Trócaire)

I'm a medical anthropologist and International Board Certified Lactation Consultant (IBCLC). Assistant Professor of Anthropology at Elon University. Opinions are my own.

4 thoughts on “Why breastfeeding mothers request and use donated infant formula

    • The main way that formula feeding leads to illness and death in emergencies (and other resource poor settings) is through bacterial contamination. Bacteria found in water, formula powder, and dirty bottles lead to increased risk of diarrheal infection, dehydration, and ultimately severe malnutrition.

      Children under 2 are especially vulnerable to this type of malnutrition. When they are not breastfed, they are also not receiving immunological protection of breastmilk.

      Formula powders are not sterile, but these are the most popular type of donation. They need to be prepared ideally with boiling hot water to be safe for infant feeding. In the case of Syrian refugees and other migrants in Europe with infants living in camps and makeshift settlements, there are simply not the resources needed to prepare formula safely. Ideally, if formula is being distributed, all of the other resources required to make it safer should also accompany it. Unfortunately this does not happen.

      Ready-to-feed liquid formulas, in the single serving amounts, are considered the best option when breastfeeding is not possible. Likewise cups are preferred over bottles for feeding, as they are somewhat easier to clean and do not harbor the same levels of bacteria.

      Globally, we are also faced with a loss of breastfeeding knowledge and support. The first line of action is often to give all mums and babies formula in emergencies, rather than considering that protecting and supporting breastfeeding is equally, if not more, important to infant health and survival.

      There are excellent resources to learn more about infant and young child feeding in emergencies from UNICEF:

      Safety precautions when feeding formula milk:
      http://www.unicef.org/nutrition/training/5.1/1.html

      http://www.unicef.org/nutrition/training/5.7/1.html

      A module on why formula donations and uncontrolled distribution of formula are discouraged during emergencies and disasters:
      http://www.unicef.org/nutrition/training/5.6/1.html

      Liked by 1 person

  1. Respiratory illness is also a cause of death when infants aren’t breastfed, as they are missing the immune protection that conferred through breastfeeding. The rate of respiratory illness increases in the winter months in Europe, so this is an especially critical time as pregnant women make the trek across Europe, birthing babies along the way. One survey of a refugee camp in Lebanon found 40 per cent of the households contained a pregnant or lactating women. There are very many infants with the women making this trek. I recently came across a photo essay of a temporary camp this summer in the centre of Athens, a major city with all the comforts of the developed world. Mothers and babies were sleeping out in the open or in tents in areas crowded with people with no toilets and no place to wash. Children were gathering water for their families in used water bottles from outdoor fountains with temporary hoses affixed. Mixing formula in those conditions is a recipe for disaster for those babies. Add to all of that the cold weather with its seasonal outbreaks of respiratory illness, including RSV (even in the US and Canada young infants with RSV who are fed infant formula have higher rates of hospitalization), influenza, and even the common cold. A mild gastro infection weakens the system, and then a respiratory illness comes along and finishes young babies off. This is what happens in most disaster areas – and these are the same living conditions we are seeing in the makeshift camps of refugees in transit.

    Liked by 1 person

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s