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In War-Torn Yemen, Controversy Erupts Over Exclusive Breastfeeding

As aid agencies grapple with rising rates of severe acute malnutrition in Yemen, they are encouraging mothers to turn to exclusive breastfeeding – a strategy that has come in for criticism in nearby conflicts.

Written by Andrew Green Published on Read time Approx. 4 minutes
A malnourished baby receives medical treatment at a hospital in Sanaa, Yemen. Mohammed Hamoud/Anadolu Agency/Getty Images

Amid the worsening conflict in Yemen, humanitarians are warning that at least 50,000 malnourished infants and children will die this year from hunger or disease. That number looks likely to climb unless a coalition led by Saudi Arabia lifts its partial blockade of Yemen’s ports and allows more supplies into the country.

Aid agencies, as they scramble to treat cases of severe acute malnutrition (SAM), have introduced a coordinated strategy to encourage mothers to exclusively breastfeed infants six months and younger, in line with recommendations from the World Health Organization (WHO). While not a panacea, they hope it can help ease the rates of malnutrition, while protecting infants against disease.

Efforts to encourage exclusive breastfeeding in nearby conflicts, like Syria and Iraq, have raised questions about how actively to push mothers, who may be exhausted and overwhelmed, to change their habits. And experts have specifically cautioned against restricting access to breast milk substitutes, warning that it might actually spur new cases of SAM.

Officials in Yemen said they are aware of these concerns, but hope to sidestep them with radio and television ads that emphasize how easy and cheap exclusive breastfeeding is, in addition to the nutritional benefits, but that avoid shaming or restricting those who do not want to make the switch.

“To push for exclusive breastfeeding, that’s already a big, big step,” said Dr. Eshraq al-Falahi, a nutrition specialist working for the WHO in Yemen. “We don’t want to start with the negative messages, or they will not accept it.”

Doctor’s Orders

Mothers in Yemen – like many women across the Middle East – have long relied on substitute products, including infant formulas and even mixtures of water and sugar. Before the war began more than two years ago, only 10 percent of women in Yemen exclusively breastfed their children for the first six months, according to Save the Children, well below the global target of 50 percent by 2025.

Breast milk substitutes are heavily marketed in Yemen, and their use is even encouraged by pediatricians who are influenced by the manufacturers, according to Anne Marie Kueter, a nutrition adviser with Save the Children. “You can imagine that if you give birth in a health facility and the doctor tells you to use formula, as a mother you’re going to believe what this doctor says is right,” she said.

And pediatricians are offering this advice despite the advantages that exclusive breastfeeding confer. The WHO concludes that the practice may help protect against diarrhea and pneumonia, while also promoting longer-term health benefits. In the midst of Yemen’s current conflict, it may also help meet the growing nutrition needs for children who are caught in the war.

Amid the ongoing fighting and the blockade, markets in some areas of the country are drying up. And prices are ballooning for those products that are available. By the start of November, Save the Children estimated that the average cost of a minimum food basket of wheat flour, sugar, red beans, vegetable oil and onions has increased 41 percent since the start of the conflict.

Some mothers who had been relying on substitute milk products, but can no longer afford them, are now looking for alternatives.

“We are seeing that these infants who used to have at least access to an alternative feeding source are now being fed with goat milk or cow milk or sugary tea or whatever is the alternative,” said Dr. Ana Nery, the medical coordinator in Yemen for Medecins Sans Frontieres (MSF). “And this has an impact on the number of patients we receive with diarrhea or malnutrition.”

Continuing to use the substitutes poses additional risks, beyond the financial. Yemen is in the midst of one of the worst cholera outbreaks in modern history and sanitation continues to deteriorate as water becomes increasingly expensive. In some areas of the country, it is difficult to find or prepare safe water to mix with some of the substitutes.

Exclusive breastfeeding, al-Falahi said, offers a critical alternative. “We have been pushing for it for years,” she said. “But in this context, we need to push even more.”

Flexible Policies

Some agencies have warned that encouraging exclusive breastfeeding in a conflict setting can backfire.

In March, MSF officials working in a hospital outside Mosul, Iraq, began seeing worrying numbers of severely malnourished children. In an interview published on the medical group’s site, the Iraqi head of mission Manuel Lannaud said part of the problem was the emphasis the international community put on exclusive breastfeeding. As part of that effort, there were restrictions put in place so mothers – many of whom lived in camps outside Mosul – could not access infant formula without a prescription.

“Many Iraqi mothers don’t breastfeed, and the ones who do usually stop after two or three months,” he said. “Conditions in the camps, combined with stress and exhaustion, make breastfeeding even harder.”

While emphasizing the importance of exclusive breastfeeding, nutritionist Suzanne Mboya’s survey of artificial feeding in Syria’s current conflict identified situations where that proved difficult, including for children who had lost or been separated from their mothers during the conflict. For those reasons, Mboya recommended a flexible response built around following international guidelines that recommend exclusive breastfeeding.

That is where Yemen is at the moment, al-Falahi said. The new five-year infant feeding strategy encourages exclusive breastfeeding, but is not punitive. Radio and television ads attempt to convince mothers of the benefits, but without criticizing them if they choose not to follow the advice. And officials are reaching out to pediatricians and other health workers to remind them to preach the benefits of exclusive breastfeeding to new mothers.

Al-Falahi hopes it will encourage behavior change, while also serving as part of a broader arsenal to reduce SAM rates in the country. But officials are avoiding any efforts to restrict access to substitutes by mothers who decide to choose an alternative.

“We just remind those mothers that it’s never too late to start exclusive breastfeeding,” she said.

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