Mother’s Milk: A Key to Eradicating Anemia in Azerbaijan
UNICEF estimates that only 12% of mothers exclusively breastfeed for at least the first 6 months of an infant's life.
After serving some tea and fresh dates, Sultanat Zulfugarova sits beside me on her sofa. She has a welcoming presence; her face is framed by soft brown curls and she wears a chic pair of prescription glasses. Her youngest of three children politely entertains herself between us with a book. Sultanat has managed to breastfeed all three of her children in a country where UNICEF estimates that only 12% of mothers exclusively breastfeed for at least the first 6 months of an infant's life.
This low breastfeeding rate in Azerbaijan relates to the high percentages of women and children suffering from anemia, which occurs when the body lacks enough red blood cells to carry oxygen. Anemia in children is known to have negative effects on growth and development, and it can cause learning and cognitive disorders. Research points to poor nutrition as well as the absence of mother’s milk in infants diets as a leading cause. Human milk contains iron that is easily digestible for infants, and also has essential vitamins, nutrients, and antibodies that help babies fight off bacteria and viruses. Mother’s milk is key to unlocking the problem of widespread anemia and improving health overall for children in Azerbaijan.
Sultanat was well aware of the benefits of breastmilk, which informed her decision to exclusively breastfeed her children. Her knowledge of breastfeeding came in part from her experience of giving birth abroad, in London, and also from her persistence to educate herself on the topic. In London, she explains that she had a lot of support in the hospital. Access to lactation consultants and breastfeeding peer-counselors helped get her started with breastfeeding, and upon leaving the hospital, she was sent home with educational materials. She described leaving London for Baku wearing rose-colored glasses. She was amazed to find the support and education she had received was not the norm here. "I thought it would be the same here, but I was shocked, especially by health-care providers. I talked to several pediatricians who were absolutely clueless about breastfeeding, absolutely,” she says.
She describes one instance in which a health care provider wanted to treat her three-month-old son with medication because he had greenish stool, an occasional but normal occurrence in breastfed babies. Sultanat decided to ignore the advice and disregard the prescription, trusting her instincts and knowledge that her baby was fine. But going against a doctor’s orders can be scary, especially for a new mom who may not know what is normal. Sultanat points out that this can be unsettling for moms, “even a question like ‘do you have enough milk?’ to a new mom is enough to make her confused.”
These experiences lead Sultanat to earn her Breastfeeding Peer-Counselor certificate and start her website, Very Important Baby (vib.az) to help mothers in Azerbaijan. It was the first website of its kind when she started it 6 years ago, and remains the only website about breastfeeding in Azerbaijan. The Facebook group linked to the website helps connect new mothers to more experienced mothers for guidance and support. There they have access to Russian specialists, to whom they can pose questions about breastfeeding. It is an important resource and a step in the right direction, but it is not enough to redirect the course of breastfeeding in Azerbaijan.
Although breastfeeding is accepted culturally in Azerbaijan, and many Azerbaijani women want to breastfeed their children, there are a lack the resources here to effectively accomplish this goal. Azerbaijani women see breastfeeding as beneficial for them and their families for a variety of reasons, from saving money on expensive formula to bonding with their baby, but under-trained medical professionals, few breastfeeding materials in their native language, and misinformation among healthcare professionals and family members are some of the factors contributing to this problem. One woman explained that her pediatrician was quick to blame breastfeeding for any problems the baby was having, for example, waking during the night, which is normal for infants. The doctor thought that perhaps she was not producing enough milk, and told her the baby’s weight gain was not very good, “the pediatrician was not even aware that there are different growth charts for breastfed and formula-fed babies.” Inara Valiyeva, faced similar challenges, “breastfeeding is quite a challenge here because everyone tells you need to start on fruit juice when the baby is 2-3 months old. Whenever the baby is crying they assume the baby is hungry, and maybe you don’t have enough milk, and therefore need to supplement with formula.”
Dr. Glenn Laverack, a public health consultant who specializes in public health campaigns. He is working with UNICEF to tackle this issue and improve exclusive breastfeeding rates in Azerbaijan. Through his research, he has identified several key factors contributing to low breastfeeding rates, not least of which being the varied advice around breastfeeding given in health care facilities. He argues that there needs to be revised standard operating procedures for all health care facilities that give clear, specific guidance on exclusive breastfeeding. "Promoting breastfeeding in Azerbaijan is not a problem because everyone universally accepts it as a practice,” he explains. What poses a challenge, he says, is that there is some misunderstanding among mothers, family members, and health care professionals about the factors that influence the duration of exclusive breastfeeding.
"This is a UNICEF priority to reduce anemia, and to contribute to the reduction of anemia in children, is to exclusively breastfeed for the first 6 months. This is where the issue is,” Dr. Laverack states.
Dr. Laverack believes that 90-95% of mothers leaving maternity units will be breastfeeding. The drop-off, down to an estimated 12%, happens within the first 2-3 months of the baby’s life. The demands of work and school mean the mother has to be away from baby, and baby needs to eat during that time. Dr. Laverack explains that in his meetings with mothers, one of the main questions they ask is about breastmilk expression, storage, and reuse. "Knowledge about expression and storage and reuse of natural breastmilk is quite low amongst mothers, we've found. But there is no cultural reason here why mothers shouldn't express and reuse, it's just not being promoted as a practice through the Health Centers." Because of this, families are supplementing with formula or introducing fruit juice and solids too early. Milk formulas are convenient, because someone else besides the mother can feed the baby. But when a mother starts missing feedings, her level of milk production decreases and her supply begins to drop. Through his work with UNICEF, Dr. Laverack hopes to help mothers and families improve these issues, “we want to find some real practical solutions to help empower women and help give women control over their bodies and their lives."
Christine Roberts, a certified Lactation Consultant, who has been working in Azerbaijan since 2014 also sees limited education around breastfeeding, both among health care providers and mothers, as a significant contributor to low breastfeeding rates. She hears a lot of the false advice given to her clients by health care providers, and sees that many of the women are afraid to question their doctor’s advice or advocate for a specific type of care. She teaches moms that the best time to first breastfeed their newborn is right after birth, and to delay all interventions before this happens. Having the baby stay by the mother’s side during the hospital stay also promotes a breastfeeding relationship from the beginning, but hospital staff don’t often allow this. “I exhort these moms to advocate for these things for themselves and their babies, but culturally it is offensive and shameful to question authority and its unusual in this culture for one person to go against the grain.”
Throughout her time working in Azerbaijan, Christine has found that many doctors don’t have a strong opinion about breastfeeding. Even if they believe it to be healthy, they don’t know how to support the mother through challenges she faces. Christine explains that if the mother has any doubts or problems breastfeeding, “the doctor will just tell her to give formula as the solution.” She describes that in the first hours or days post-birth, the hospital staff do not help the mothers breastfeed, and that many hospitals do not have breast-pumps available for mothers or teach mothers how to manually express for their babies. Leaving the hospital without understanding how to breastfeed and/or express fresh milk leads to problems down the line. “In my experiences, women will give a [formula] bottle, either for a temporary convenience or other reason, and it can completely derail breastfeeding for them.”
Nigar Hajiyeva, Associate Professor of Pediatrics at Azerbaijan State Advanced Training Institute for Doctors, sees the delay in breastfeeding immediately after birth as one of the main issues contributing to low breastfeeding rates in Azerbaijan. “These kinds of practices make it difficult to breastfeed the child, because once baby tastes formula it becomes challenging to persuade him to be breastfeed.” Thus, one of the main issues, she argues, is incorrect feeding practices in the maternity wards. She explains that seldomly mothers are well prepared for the birth of their children and aware of the importance of breastfeeding. Nigar herself stresses the importance of breastmilk for babies, stating that it is the most nutritious source of food for children up to 2 years of age.
It is clear that more breastfeeding education is needed for both for health care providers and for families. In order to decrease anemia and increase the overall health of children in Azerbaijan, having patients and providers educated and informed will help establish a foundation to move closer to this goal. This means, as Dr. Laverack has established, creating standard operating procedures by which medical facilities and health care providers can operate. Just as important is making available educational resources for mothers to take control of their child’s health and well-being. Availability and affordability of breastpumps, and education on how to properly use them and store human milk, can make introducing a formula bottle less tempting. But in addition to all this, it is clear that working towards an atmosphere where open dialogue between provider and patient can exist is equally vital to progress.