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Despite high breastfeeding initiation rates in Serbia, Bosnia, and Croatia, fewer mothers are still nursing when their babies are six months old. What obstacles prevent mothers in this region from nursing for longer? SteadyHealth investigates.

Across all four regions, an overwhelming majority of respondents reported initiating breastfeeding: 92.26% in Serbia, 95.8% in the Federation of Bosnia and Herzegovina (in the rest of the text, FBiH), 91.67% in the Republic of Srpska entity of Bosnia and Herzegovina (in the rest of the text, Srpska), and 95.74% in Croatia.

The World Health Organization strongly recommends that infants be breastfed or fed breast milk exclusively during the first six months of their lives, meaning no formula, no supplementation with water — simply said, nothing but breast milk. Among respondents in Serbia, 14.95% reported that they exclusively nursed at least one child for a minimum of six months, slightly more than the 13.7% suggested by national data from 2010. National data from the whole of Bosnia and Herzegovina showed that 17.6% of mothers exclusively breastfeed their children up to six months of age, while 9.5% of our survey respondents based in the Federation of BiH and 16.67% of Srpska-based respondents did. Almost 16% of Croatian participants said that they followed the WHO’s guidelines on breastfeeding with at least one child, though national data from 2011 showed that 54.2% of mothers did.

When mothers who self-identified as not having breastfed answered our question delving more deeply into the reasons why, those who nursed their babies for a very short amount of time responded alongside those who never breastfed at all. 

Participants were offered a multiple-choice answer format and in addition received the chance to tell us why they did not breastfeed in their own words. In three of the four surveyed regions, “I didn’t have breast milk” or “I had an insufficient amount of breast milk to feed my baby”, an answer that was not part of our multiple choice list, proved to be the most popular reason for formula feeding. That is, 27.1% of Serbian respondents, 27.27% of Srpska respondents, and 36.36% of Croatian mothers who took part in our survey responded this way. Only in FBiH was “my healthcare provider recommend I formula feed” the most prevalent reason for not breastfeeding.

This could partially be explained by our findings that significant numbers of mothers were unable to breastfeed on demand while in hospital because their babies were in the hospital nursery, and that healthcare providers frequently formula feed babies without their mothers’ consent.

What else could be behind these beliefs, though? SteadyHealth spoke to Milena Popevic, a peer-to-peer breastfeeding advisor with the popular “Association of Parents”, from Serbia. Popevic explained:

"I believe it is because maternity hospital staff ‘fills their heads’ with this notion. It’s not unusual for staff to say: ‘You got nothing; you won’t be able to breastfeed’. Or they say, ‘we have to use formula because your milk hasn't come in yet’, though they already have colostrum.

These women go home with the idea that they don’t have enough milk. If their babies also don’t latch on properly, it is possible that they aren’t taking in enough milk, and that they become nervous and cue that they want to nurse all the time. Mothers then conclude that their babies are hungry and that they don’t have milk because their babies keep wanting to nurse."

“Stereotypical” reasons for which mothers choose formula over breast milk, such as believing formula to be more practical, wanting free time for oneself, and having to go to work and leave the baby in the care of others, appeared surprisingly low down on the list of reasons for which participants did not breastfeed.

Across all four regions, significant numbers of mothers did give "I knew nothing about breastfeeding" as the reason for which they chose formula: 22.9% in Serbia, 23% in FBiH, 15.15% in Srpska, and 22.73% in Croatia.

Across all four regions, significant numbers of mothers did give “I knew nothing about breastfeeding” as the reason for which they chose formula: 22.9% in Serbia, 23% in FBiH, 15.15% in Srpska, and 22.73% in Croatia.

This lack of knowledge was clearly not something that was overcome with the help of the healthcare providers these mothers encountered during their pregnancies and their stay in maternity hospitals.

Among the group of women who self-identified as having breastfed, around a third of women reported that they received practical tips on succeeding at nursing within the maternity hospital. Likewise, 30.42%, 23%, 21.99%, and 28.16% of women in these same territories shared that they had encountered breastfeeding challenges of any kind but received healthcare provider help to overcome them.

Almost a quarter of Croatian mothers were able to breastfeed their babies within their first hour of life, something the World Health Organization considers an important life-saving measure that both confers antibodies to newborn infants and helps prevent postpartum bleeding in mothers.

In FBiH, however, a lower 18.9% of respondents were given the chance to nurse their babies within the first hour, while 12.06% were able to do this in Srpska. Serbia had the lowest rate of breastfeeding initiation within at hour, 7.69%

Within Serbia, 17.48% of participants’ babies were fed formula without their consent by healthcare staff, while 18.7% were unable to feed their babies on demand as they were placed in the hospital nursery. The same held true for 30.5% and 17.02% respectively in Srpska. In FBiH, 31.7% of participating mothers also responded that their baby was given formula without their permission, though only 8.8% said they were not able to feed their babies as necessary because they were in the nursery. In Croatia, almost 34% of mothers shared that their babies were given formula without their consent, but again, a much lower percentage, 4.6%, missed out on the chance to nurse their babies on demand due to being separated from them.

We asked Ivana Dimitrijevic-Robertson, a La Leche League International leader from Serbia, to elaborate on this situation. She shared:

"I don't believe there are many obvious formula promotion code breaches in Serbian hospitals today, though I believe there must be backroom deals with individual pediatricians and pediatric nurses taking place. It is very common, for example, that mothers of newborns experience some pressure from the health visitors who visit the mothers at home within the few days following hospital release to offer a particular brand of formula to the baby without indicating a clear reason, or assessing the breastfeeding dyad appropriately.

It is hard to understand the real motivation behind this. It could be a lack of training, but I suspect subtle corruption to be the real reason behind most cases. I don't believe many maternity care providers genuinely believe formula to be a better way of feeding infants, but I think suspicion in the mother's ability to breastfeed is much more common than support. A 'fed is best' sort of attitude is also very common, which seems to imply that a large number of women aren't able to meet their babies' nutritional needs by breastfeeding, and also that formula is of equal nutritional value, if not better than the mother's milk. Again there are many reasons for this sort of attitude, but it boils down to a systemic disregard for motherhood."

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