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HOW to respond to requests for BMS from caregivers who are ineligible for BMS Support

This question was posted the Infant and young child feeding interventions forum area and has 4 replies.

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Isabelle Modigell

Independent IYCF-E Consultant

Frequent user

10 Jul 2022, 22:40

Dear colleagues, 

I am seeking training materials, experiences, approaches/techniques and your recommendations on HOW, as an IYCF Counsellor, to respond to requests for infant formula from emergency-affected mothers/caregivers who are NOT eligible to receive infant formula/BMS according to pre-established eligibility criteria? 

Put another way, as an IYCF Counsellor working within an IYCF-E Response that includes the targeted and controlled provision of BMS to eligible caregivers of BMS-dependent infants, HOW DO I REFUSE an ineligible caregiver in a way that is effective, compassionate,  respectful and minimises caregiver stress? 

WHAT should an IYCF Counsellor say, do and/or take into consideration?

Your responses will be used to inform the development of content for a new Training for Frontline Workers: MHPSS-INFORMED INFANT FEEDING COUNSELLING IN EMERGENCIES. The training will include a module on how to navigate tricky/complex issues which IYCF Counsellors commonly encounter during emergencies e.g., dealing with requests for infant formula from breastfeeding women who are ineligible for BMS Support. (Note that past refusals have reportedly resulted in camp riots/protests, taking of BMS by force and threats against health workers - while evidently part of a wider communication/sensitisation challenge, it does highlight the importance of IYCF Counsellors responding  appropriately).   Ethics  and WHY breastfeeding mothers request BMS during emergencies will be covered, in addition to the "how to" guidance in question here. 

This question is being posed with the understanding that providing infant formula to facilitate maternal choice when it is likely to cause significant harm is not kind or ethical  (Gribble, 2014). To allow for a focused discussion, please note that I am currently not seeking inputs on whether infant formula should be provided to all emergency-affected mothers who request it or not. 

With thanks to Dr. Karleen Gribble and Dr. Aunchalee Palmquist, whose insightful paper on Facilitators of good and poor practice in distribution of infant formula in the 2014–2016 refugee crisis in Europe inspired this question: "Crucially, frontline aid providers, including medical personnel and those providing nutrition support, need to be equipped with infant feeding counselling skills so they are able to appropriately support and assist mothers and caregivers requesting infant formula, including those who are refused. Strategies used in medicine to prevent inappropriate prescription of medications that can cause harm when dispensed improperly may be instructive (Wells & Cronk, 2020; Wyse et al., 2019)."

With many thanks in advance,

Isabelle 

Maryse Arendt

Lactation consultants Luxemburg BLL - IBFAN

Normal user

12 Jul 2022, 15:56

it would first need a counselling dialogue with the mother to find out why she wants BMS? Is it prestige, a perceived more modern behaviour, a perception of not enough milk, not enough milk, or afraid of not having enough milk, sexual tabous, sharing infant care or planned absence of the BF mother.........

Further the insistance of mothers to get BMS is linked to the fact that the promotion of BMS is very overwhelming and imprints mothers/ parents and their environment!

It would help to have unbranded "unattractive" packages to distribute!

There is a need correcting the myths on BMS and clear information on breastfeeding and breastmilk to happen at the best befor the demand for BMS is there: "Breastfeeding has often been described as cost free.1 It is not free. Breastfeeding requires investment to overcome the sociopolitical barriers that exist in many countries2,3 through the eff ective approaches and practices described in the second paper of the Lancet Breastfeeding Series.4 As shown in the fi rst Series paper, infants, children, and mothers who do not breastfeed experience an increased risk of mortality and morbidity.5 Breastfeeding is nutritionally, immunologically, neurologically, endocrino logically, economically, and ecologically superior to breastmilk substitutes (BMS), and does not require quality control of manufacture, transport, storage, and feeding mechanisms." Quote from: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)00103-3/fulltext

Daniel Takea

Public Health Nutritionst/ Independent Consultant

Normal user

13 Jul 2022, 17:10

In order to address the questions, first of all, we should have to consider the type of emergency, location, context of the displacement such as the socio-economic, culture, religion and educational backgrounds. As an IYCF counselor working within an IYCF-E response, our approach responding to an emergency in developing and devloped countries vary. During complex emergency response especially in developing countries basic availability and accessibility of services such as: Health and Nutrition, food, WASH, Shelter, education and livelihood are ill served. Thus, requests for BMS from ineligible caregivers is huge, literally if the BMS provision is at food distribution site with other relief commodities and if the market value for BMS is high. However, if the provision of BMS is supported by Health/Nutritionst at Health facilities and or BFHI with strong HEALTH related SBCC then caregivers will realise the eligibility criteria and give up their requests with know-how effectively.

Karleen Gribble

Adjunct Associate Professor, Western Sydney Uni

Normal user

14 Jul 2022, 02:59

Hi Daniel,

I agree with you that having health/medical organisations/staff in charge of BMS distributions is a great help in terms of enabling distributions that are ethical and in line with the OG-IFE. 

I think that it is very helpful for emergency responders and organisations to know why mothers and other caregivers are requesting infant formula and for counsellors to use this knowledge in their work. Exploring why women are requesting infant formula is therefore critically important. In many instances it will be because they believe that they do not have sufficient breastmilk for the infant and in most instances this will not be true. Helping women through counselling to accurately assess their situation can remove any need to refuse providing infant formula. Other reasons for request such as wanting to obtain a high value product for resale or where the request comes from an aspiration to formula feed, will need a different counselling response.

Rukhsana Haider

TAHN Foundation

Normal user

14 Jul 2022, 06:06

Hi. I appreciate Daniel's and Karleen's suggestions about how caregivers who request infant formula need to be handled. We need to be very careful that in addition to appropriately counselling the caregiver, identifying her conserns and reason for the request in an empathetic manner, practical assessment of her ability to breastfeed adequately or not, is provided by skilled breastfeeding counsellors. I have come across 3 main reasons for requesting infant formula in such cases; 1) anxiety, stress/depression because of the disaster, displacement from home and/or loss of lives/livestock, household goods,  2)  perception of or actual insufficient milk as a result of the above, and 3) lack of privacy to breastfeed at shelters. There is a 4th reason, which we may not like to accept, which is is that many requesters/recipients of the infant formula (or other baby food), want to get these so as to sell them in the market (I have seen packets of RUTF openly on sale in markets). 

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