“If anyone can eat publicly, so can babies"

In an interview for UNICEF BiH, Professor Emina Hadžimuratović, Ph.D., paediatrician at the Paediatric Clinic in Sarajevo, Associate Professor of paediatrics at the Faculty of Medicine in Sarajevo and IBCLC breastfeeding and lactation consultant, talks about the importance of first few days of lactation for establishing breastfeeding, and the need for greater support to mothers wishing to breastfeed, by the health care system and by the society, the closest family members, but partners too. She also underlines the importance of breastfeeding at times of crises, under economic strain, and the importance of breastfeeding in reducing inequality. She also explains how breastfeeding helps mothers lose weight after giving birth, and answers some of the questions asked by mothers in a huge response to the recent interview with Professor Hajrija Maksić, Ph.D. President of the Association of Paediatricians in BiH, who also spoke about the importance of breastfeeding for child development, mother and baby health, raising awareness about the importance of breastfeeding, and the long-term positive effects of breastfeeding on child development and mental growth.

According to the currently available data, breastfeeding rate in the first month of baby’s life is 87.3%, however, by the sixth month, only 15.1% of mothers only breastfeed. Why do we have such numbers?

According to these numbers, it seems that we are off to a good start, and that breastfeeding gets quickly and easily abandoned. The fact is that the establishment of breastfeeding is a process, and that in the first month of life, lactation has not yet been established, and at the end of the first month, mothers believe that they do not have enough milk, and they reach for infant formula. The first days of lactation are the most important, and it is important that at that time, a woman receives appropriate help from the health care system and her environment. It is also very important that the mother has prior knowledge about breastfeeding, so more work on promoting breastfeeding needs to be done with pregnant women and they must already have information about the lactation process.

Is breastfeeding sufficiently discussed publicly, having in mind the importance of this topic?

Our society lacks groups that would deal with breastfeeding support, and it's not only health workers that need to be a part of them. Those can be associations of mothers or similar associations where they would exchange experiences. Given the low rate of breastfeeding, a mother who breastfeeds is a minority in a way, and in her surroundings she does not have enough girlfriends and acquaintances who are breastfeeding, or who have the experience of breastfeeding. So there is definitely lack of space and organisation where mothers and women with experience in breastfeeding would in some way support mothers who are just embarking on that journey.

Mothers will often complain that they have no adequate support when starting breastfeeding, not even from the closest family members, and that there are often attempts to talk them out of it. Why is that the case?

Mothers of the present day are the daughters of a generation that breastfed very little, because at their time, the pharmaceutical industry at one point had the upper hand. During that period, the health care system recommended infant formula, and under the pressure of the pharmaceutical industry, breast milk was considered inadequate, and this industrial preparation better than the breast milk. So today's mothers are actually the daughters of women who don't have much experience in breastfeeding, because they didn't get a good opportunity to gain it, partly because of the working hours that didn't allow them to leave work to breastfeed, or because of the shorter maternity leave. Feeding infant formula to your child was considered to be modern, correct, and okay.

How important is it to change such perception?

Nowadays, things have been reversed back to the fact that breastfeeding is the only natural and the best way to feed a child, completely free and available at any time. The significance of breastfeeding is also great in crisis situations, in case of water and power cuts, in case of an earthquake, fire or any other disaster, babies of breastfeeding women would be able to survive all of that with less trouble. Ultimately, breastfeeding has been proved to save children's lives, and according to the World Health Organization (WHO) estimate, somewhere around 800,000 children's lives are saved annually thanks to breastfeeding, because those are children who have no other source of food. Also, when it comes to people on the move, in such situations too, breastfeeding makes it easier for mothers to provide for their babies.

To which extent does breastfeeding contribute to reducing inequality?

Another major advantage of the mother's milk is that it is completely free, which is very important under specific economic circumstances, in which we can say our country finds itself too, and the crisis is a global phenomenon. Breastfeeding is important in reducing inequality, and that is why it is especially important that all mothers have access to health care resources that can support them in establishing and maintaining the breastfeeding. Unfortunately, the distribution of resources, not only of the health care system, but also of the society that can support them in breastfeeding, is uneven, and this is certainly something that this year's breastfeeding week, whose motto is Reducing differences - support to breastfeeding for all could encourage us to do, and work should be done on information reaching women in areas where they cannot be adequately supported by the health care system.

You mentioned the advantages of breastfeeding in times of crisis. To which extent does breastfeeding make the lives of women who are not in crisis easier?

For infant formula, you must have sterile water at a certain temperature, you must try to keep everything clean, while breast milk is always clean, always sterile, at the ideal temperature, and always ready to feed the baby. Women have the wrong idea that breastfeeding will tie them to the house, deprive them of the opportunity to see their friends, or to be part of social life, and mothers generally feel this way after giving birth. They feel that they lost all their identities and turned into mothers only. That's what I went through, and every woman goes through that. Suddenly you are not a doctor, a professor, a director, or anything, you just feel like a woman who sits at home and breastfeeds a child. In fact, it's just the opposite – breastfeeding allows the mother to take her baby anywhere without any additional equipment.

Breastfeeding in public?

If everyone has the right to eat in public, babies must have that right too. Breastfeeding in public can always be done in a dignified and acceptable way, to preserve the dignity of both mother and child. Breastfeeding in public - yes, because if everyone can eat in public, why can't babies? In addition to influences from the surroundings, one of the main obstacles to breastfeeding in public is the lack of adequate places where mothers can breastfeed, and only a small number of health care institutions have designated areas for breastfeeding and changing babies. This is something that should definitely be addressed in the future, because if such places were marked, the mother would surely feel that breastfeeding is recommended and supported by both the health care system and the society as a whole.

While women breastfeeding in public often face judgement, on the other hand we see woman who are not breastfeeding being stigmatized…

No mother should be judged for choosing not to breastfeed. No one should be stigmatized and a mother should not be declared to be a bad mother because she decided not to breastfeed, which is her absolute right. This does not make her a less good of a mother, she must not suffer any stigma, or be condemned by society. Before making that decision, the mother should be informed about all the benefits of breastfeeding, how important breastfeeding is for the child's development, and that it is a way to ensure the child's health.

What does a mother need to know when making a final decision?

Breastfeeding has numerous long-term and short-term positive effects on both mother and baby's health. The short-term effects are that it reduces the incidence and severity of various acute infectious diseases, primarily respiratory and gastrointestinal ones. There is less probability that a breastfeeding baby will get sick, and if (s)he does get sick, the risk of a severe form of the disease and hospitalization is much lower. As for the long-term effects of breastfeeding, babies are less likely to develop a number of chronic diseases, such as certain allergies or autoimmune diseases, type 2 diabetes, obesity is nowadays also linked to low breastfeeding rate because every fifth child in our country is obese, which is a major public health problem. Breastfeeding reduces the incidence of childhood malignant diseases, and breastfeeding definitely has a stimulating effect on the child's neurological development, because breastfed babies are in much more frequent contact with their mother, where "skin to skin" contact with the mother is a particularly important stimulus that always has a positive effect on neurological development. Babies fed with infant formula have selective contact with the mother, which is mainly related to feeding, and it does not always have to be the mother feeding them either. Feedings are much more frequent, the intervals between them are shorter than when the baby is fed with infant formula. So, with breastfeeding, there is much more contact and much more stimulation. It has been proven that when tested at the age of seven, breastfed children have a higher IQ.

What are the positive effects of breastfeeding on mothers?

Breastfeeding is also very beneficial for mothers. First of all, it helps them to reduce weight gained during pregnancy, which can certainly be a good motivation for mothers. A breastfeeding woman produces in one day as many calories in milk as she would spend playing basketball for two hours, and this affects weight loss, of course, with a balanced diet. The mistake that mothers often make is that they think that when breastfeeding they should have an excessive calorie intake. This is a matter of tradition to a certain extent, as there is popular belief that the milk will be better and stronger with increased calorie intake and food consumption. A breastfeeding mother should have a normal and balanced diet, and should not consume more calories than a non-breastfeeding woman, or slightly more, up to 50 or 100 calories. Thus, breastfeeding will allow her to lose weight. In addition to reducing body weight, breastfeeding also helps mothers restore their reproductive organs to their pre-pregnancy state, due to all the hormones secreted during lactation. It reduces the incidence of ovarian cancer and breast cancer, so breastfeeding is very important for the mother's health.

Mothers often claim inadequate support in establishing breastfeeding while in the maternity ward, and particularly after being discharged home. Is the support sufficient and adequate?

Our maternity wards are absolutely supportive of breastfeeding and are organised according to the rooming in system, which means that mom and baby are in the same room, and things were organised this way to support breastfeeding. The baby is not separated from the mother, health care staff are trained to support breastfeeding, however the mother's stay in the maternity ward is essentially short. After a natural birth, the mother stays in the hospital for 24 hours, and after a caesarean section, a few days longer. This is too short a period to convey all the knowledge a mother must have about breastfeeding. The first next regular visit to the health care system after the mother and the baby had left the maternity ward is scheduled for vaccination, and by then the baby is already one month old and lactation has either already been established, or the mother has already given up breastfeeding. A lot of time passes between the discharge from the maternity ward and the next contact with the health care system, unless of course there has been some other reason for the visit in the meantime, baby's illness or some complications. That is why it is important that after the maternity ward, other resources of the health care system get involved more, and I am primarily referring to the home visit service. Help in those first days is crucial, because it is the riskiest period for giving up breastfeeding.

How important are the breastfeeding support centres and other similar initiatives?

Through the UNICEF project Reduction..., four breastfeeding support centres were opened in small towns - Bihać, Sanski Most, Kalesija, Gradačac, and Kakanj, and according to the feedback I have, they functioned very well and were a great support to breastfeeding in those places. So, opening of such centres in health care centres certainly helped a lot to raise the breastfeeding rate in our country. UNICEF has in general been carrying out a high-quality continuous campaign aimed at mothers, which is very good, and serves to directly stimulate mothers to breastfeed, considering that motivation is something that has also been lacking lately.

How important is the support of family and partner in the process?

Family's support is very important for the mother. It is believed that the ability to breastfeed is inherent in women, and that by carrying a pregnancy and giving birth, they automatically know how to breastfeed. However, breastfeeding in the human species is no longer an instinctive activity and it actually has to be learned, and much more preparation for pregnancy should be organized, because when women have certain knowledge, they will feel more at ease and safer. Pregnancy is the right time for both the future mother and her partner to learn about breastfeeding and about the important elements on the way to establishing breastfeeding. In addition to the support of the health care system, partner's support is crucial. The beginning of breastfeeding can be difficult, painful, and stressful, a woman sometimes fears she will not be able to do it all, and in order to overcome it, it is very important to have a partner who will encourage and support her along the way.

How does a mother know if a child has had enough milk?

Another problem is that we have learned to quantify everything, and women want to know and feel more secure when they know how many millilitres of milk their baby has consumed. When a baby is breastfeeding, no one knows exactly how much milk (s)he has taken in, but when the baby is well, satisfied, has a sufficient number of stools, and plenty of wet diapers, these are appropriate indicators that (s)he is getting enough milk. I do not advise mothers to weigh their children themselves, this can put a lot of pressure on them. They simply need to relax and indulge in breastfeeding, after they have learnt about the basics of breastfeeding techniques or received this information from the health care system. I advise pregnant women to watch videos from relevant sources on how to start lactation, and to start with information on how to position the baby on the breast, which is actually the most important first step in the process of establishing lactation.

Some of the mother’s responses included the issue of hyper-lactation, and the possibility of a mother with surplus milk supporting the mother with no or insufficient quantity of milk…

Historically, this was indeed done in the past. Modern medicine does not recommend such spontaneous behaviour, among other things, because of the possibility of transmission of certain infections, primarily cytomegalovirus infection. Today, it is not recommended that mothers share milk in this way without medical control and supervision. Considering the large increase in the rate of premature births in our country and globally, we would need a bank of human milk, where it would be stored safely. In such banks, milk is tested for certain infectious diseases, and mothers who donate milk must meet certain criteria. Milk is taken under medically controlled conditions, and this milk is the best source for feeding premature babies, or babies who, due to some other condition, have to stay in the hospital and cannot take their mother's milk. Mothers of prematurely born babies also became mothers prematurely, and in the same way, they are unprepared and the process of breast preparing is not completed, they are separated from the baby and have to establish lactation in an artificial way. In such situations, another mother's milk, which would come through a milk bank in a medically controlled manner, helps a lot. A human milk bank is absolutely necessary and doable, it only takes a first step to be finally taken and it's something that we could certainly do in the future, with the help of international institutions.