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 . If a woman is severely malnourished, feeding the mother will enable her to feed her baby.
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 . 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.
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.
- 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.
- Hill, P.D., et al., Psychological distress and milk volume in lactating mothers. Western Journal of Nursing Research, 2005. 27(6): p. 676-693.
- 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.
- 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.
- 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.
- UNICEF. The costs of formula feeding. 2005 1 June 2013]; Available from: http://www.unicef.org/philippines/downloads/infokit final.pdf.
- Whitehead, B. Bfing in an emergency. 2005 1 June 2013]; Available from: http://community.lsoft.com/scripts/wa-LSOFTDONATIONS.exe?A2=LACTNET;58401ddb.0505A.
- 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.
- 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.
- 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.
- 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)