Monday, March 8, 2010

Breastfeeding in Haiti-- a complex social issue.


This is really long. I totally get it if you don't want to read on...

Breastfeeding in Haiti is a complex social issue. Now, let me start off by saying that I don’t feel like I have a ton of credibility to speak on this issue. I am not an expert on anything lactation-related. This is just based on what I’ve read and observed as I’ve lived and worked in Haiti. I have a pretty typical “American” view of breastfeeding. I totally think breastmilk is best, but I don’t think formula is poison. I wasn’t an extended nurser of my children. I weaned Nia at 9 months because I was offered a free trip with Nick to Disney World. Was ready to do so anyhow and seemed like (and still seems like) the right choice. Josiah (with his heart surgery + feeding tube scenario) was a different story. Long story short. I pumped round the clock (every three hours) with him for 3 months. I did give Nico (the son we adopted) some breastmilk a few times when he first came home (since I had it for Josiah anyway) and even offered to let him nurse once when he asked to. But he didn’t get it. And it felt kind of weird. So I didn’t continue. I come from a family of extended breastfeeders. My sisters both nursed their babies past the age of 2—totally doesn’t weird me out and I see the health benefits. You simply can’t argue with them. Different strokes. So that’s my view on American breastfeeding. I really don’t have a whole lot of passion that’s wrapped up in discussing it.

Breastfeeding in Haiti is a totally different thing. I am sort of a lactivist here in Haiti. I’ve talked to a lot of Haitian mamas, a bunch of Haitian healthcare workers and read a lot about breastfeeding in Haiti, because I think it’s one of the biggest social issues we face here. There are a lot of social pressures and superstitions that prevent babies being nursed. Here’s a few very common “folk beliefs” about breastfeeding in Haiti that are widespread and culturally accepted as true. (All the quotes below are taken from “Third-World Folk Beliefs and Practices: Haitian Medical Anthropology” put out by the Institute of Haitian Studies, University of Kansas.)

Superstition #1—Colostrum is poisonous

“Colostum (lèt jòn) is regarded with great suspicion; to be expressed and disposed of.” (pg 103) In its place, “a strong purgative (lòk—composed of ingredients such as crude castor oil, pork fat, nutmeg, garlic, cinnamon, and various leaf brews) is given the neonate very soon after birth to expel the meconium. Some observers believe the lòk so harmful that is a disguised elimination of weaker children. This is often followed by labouyi lanmidon (literally: starch porridge), made with laundry starch, sugar and cinnamon, mixed in water—believed to be a further purgative as well as nutritious.” (pg 94).

So MANY, MANY babies in Haiti miss the nutrient-rich, antibody filled, immunity-providing colostrum. I have heard of this first-hand in Haiti, and also read about this phenomenon in a book put out by Jeanne DeTellis (“A Stubborn Hope”) who lived in Haiti for many years.

Okay, so if that were the only problem, and women were still willing to nurse after their milk was fully in, it wouldn’t be the ideal, but it would still be fine. (Probably.)

But there are a lot of other folk beliefs that make breastfeeding seem like a bad option. Again from the book I mentioned earlier:

Superstition #2—The spoiling of mother’s milk

Lèt gate or move lèt (spoiled mothers milk) can be caused by an emotional trauma, or even by just one violent argument. The milk then becomes a poisonous substance, and the baby must be weaned immediately… Also can be caused by an interruption of 24 hours or more of breastfeeding.” ( pg 25) It is also believed that this condition can also be caused by sexual intercourse during nursing, “Sexual intercourse should not take place during the nursing period, because sperm poisons the mother’s milk, and thus the baby.” (pg 104) (The author then goes on to say that though this is believed, is rarely honored.)

Superstition #3- Breastfeeding can cause mental illness

“During pregnancy, mother’s milk builds up, distributed throughout the entire body, in the same way as her blood. The nipples later serve as focalizing conduits. Care must be taken to prevent the milk from mixing with any move san (bad blood) which would be harmful to the child, or from making its way up into the woman’s head, which could cause permanent mental illness.” (pg 24) (Side note: I personally know a woman who is mentally ill here in Jacmel that people claim happened in this way.)

Superstition #4- Worms

“Mother’s milk can cause worms in a child. When breastfeeding ends, the worms go away.” (pg 25)

Superstition #5- You can't nurse while pregnant

“If a mother becomes pregnant again while still nursing, her milk from then on must be reserved for the fetus. Should the child which was being nursed then try to “steal” any of her milk, this child will become sick.” (pg 103)

Okay, now onto a whole OTHER side of the issue—the “free” factor. Generally in Haiti (and I don’t have a quote to back this up, but I do have TONS of anecdotal evidence) when you give something away people will generally want it, but there’s a perception that something free is insuperior to something you have to pay for. This is why many clinics (even for the very poor) will charge a very nominal fee for medical care. For some reason, it seems that Haitians feel that something they pay for is worth more. Therefore, it is reasoned by many that if you have to PAY for formula, it MUST be better than breastmilk, which is free. And so therefore, it also becomes very much a social status thing. People who can afford formula usually will give this to their babies rather than breastfeeding them.

This presents TONS of problems. Especially in a country like Haiti (or really any developing country) where people see starving children and want to “help.” Therefore, (get ready for a big generalization) white people come in with their week-long “white people clinics” (as a fellow ex-pat here calls them) and give out free formula to babies who are malnourished.

In my opinion, this is the ABSOLUTE WORST THING you can do. ABSOLUTE worst. Why you ask? Thanks for asking. Let me tell you.

Purchasing formula is NOT a sustainable for Haitian families. (Unless we’re talking about the really, really wealthy ones, and then we’re not really talking about the same issues, because they would relate more to the “American” breastfeeding norms.) Formula is MORE expensive here in Haiti than in the states. And I am not speaking comparatively. It’s LITERALLY more expensive. The same amount of formula purchased in Haiti would be nearly double the cost that you’d pay in the US. (Because remember, it all has to be imported.) But Haiti is not the US. The US is the richest country in the Western hemisphere. Haiti is the poorest—80% of people live under the poverty line, and 54% live in abject poverty (CIA World Factbook). Even in the US, formula is cost-prohibitive for many. It’s not even worth mentioning on the same scale… Essentially NO one here can afford formula.

So, let’s make the direct correlation between the efforts made by well-meaning individuals who are trying to “heal” malnutrition. They give the mom a week or two supply of formula. It’s a “prescription” of sorts—give the baby some extra calories so she can get well. The problem is that the mom starts giving the baby the formula. (And we’ve already established that this mom now thinks that the formula is a superior option.) So she mixes up the formula and starts feeding the baby bottles of it. And she stops nursing. And then her milk starts to dry up. Or, worse she starts believing the following…

Superstition #6—The "Milk Sack" disappears

“It is believed that there is a sack or pocket in babies which received the mother’s milk. When the child is weaned, this sack is supposed to disappear and not take milk again. If the child becomes ill after weaning (as is frequently the case), naturally there is much speculation concerning the milk sack. Sometimes it is thought necessary to give a purgative so that the child will expel the milk sack; the stools are then carefully watched for its presence. If, for example, during the night a child should return to the breast after having been weaned, it is considered disastrous, since (s)he will no longer have a “milk sack” to receive it.” (pg 104)

Now, let’s also remember that in her mind too, it may be very likely that a 24 hour interruption of breastfeeding might cause her to believe that her “milk has spoiled.”

Is the picture coming into focus for you? Providing free formula to ANY mother who CAN breastfeed in Haiti is not okay with me. (Now, yes, there are always exceptions—there are always people who CANNOT breastfeed due to severe malnutrition, AIDS, etc. I am not talking about them.) I feel it starts a vicious process that leads to babies not only NOT being nursed, but also starving to death as there is not a sustainable way to provide them with a breastmilk alternative (ie formula) in the long-term. So instead, moms will begin feeding their very little babies table food (like meat, rice, milk, etc.) all ground up and made into “baby food.” (And in all reality, most Haitian moms will feed their kids this kind of table food very, very early regardless of whether they nurse or not. (As in when they are merely DAYS old—again can give you lots, and lots, and lots of anecdotal evidence that I’ve personally witnessed to this end.)

So it seems obvious—teach exclusive breastfeeding. BUT, believe it or not (sarcasm alert) it’s not just a matter of walking around with megaphones telling people “breast is best.” I mean, come on, the facts are there. Should be SO obvious. (And not for nothing, but exclusive breastfeeding decreases the likelihood repeated close pregnancies, decreasing both mother and infant mortality.) It just makes SO much sense to me. BUT... these are DEEPLY held cultural traditions. Not something you can just come in and change just like that. I am pretty outspoken about it. (Imagine that, Gwenn Mangine, outspoken? I know, right?) Whenever I am handing out diapers in the refugee camp, I pretty much ask every mom if she’s breastfeeding exclusively. I explain the benefits. I explain the risks of not doing it. And most times I just get a glazed look and head nods that tell me they are really not listening and just want me to give them free diapers.

For a while I couldn’t explain to people WHY this is so hard to explain to Haitian people. But then Nick helped me think of a perfect analogy. Americans are fat. (And yes, I include myself in that group.) We eat a lot of McDonalds. And Wendy’s. And Burger King. And Hardees. (MMmmmmm…. Thick burgers… you have no idea what I would do for one of those things right now…) It’s really bad for us. We know that. And YET, we continue to get fatter. Doesn’t matter how many documentaries are made, doesn’t matter how many studies are released. We somehow believe that eating greasy trans-fat filled food is a good option for us. We must believe that. Because we eat it. And we get fatter. And we make our kids fat. By doing this aren’t we hurting our kids? We wonder why we can’t convince Haitians that we have the best medical advice. But I guess my question would be something closer to this—why can’t we convince Americans (who ARE educated AND know the facts) that we too are killing our kids? We might not be killing them as quickly, but we are killing them with diabetes and heart disease... How is this any different?

So yes, breast is best. I would even go as far to say that in Haiti, breastfeeding vs. formula feeding is not an issue of best vs. fine. (Which, I would say, in the States, that’s what we’re dealing with.) Here I believe it’s an issue of life and death. But so are a lot of things here. And a lot of things everywhere.

And there’s no easy answer.

Ok—done with my thoughts on this. My brain is tired. But there are three disclaimers I need to make…

#1—I don’t think week-long white people clinics are bad. They do a lot of good work. They save lives. They are necessary.

#2—There are a lot of good programs in Haiti that aren’t leaving moms stranded and forced to starve their children. Don’t mean to insinuate that there aren’t groups trying to address this. There are two really great women's programs I am aware of that focus on prenatal, birth support and follow-up care. Check them out here: http://www.olivetreeprojects.com/ and here: http://heartlineministries.org/womensprogram.aspx

#3— You might be wondering why I am collecting formula right now if I am so dogmatic about this breast-feeding thing. The formula that I am collecting right now is going to babies who are orphaned (at least by their mother) or to babies with mothers who LEGITIMATELY cannot breastfeed. This is the ONLY option and so being a sustainable supply for orphaned babies to get them through their first year seems like a good plan. Especially in light of the number of newly orphaned babies...




13 comments:

  1. WOW! I understood SOME of the issues of why indiscriminately handing out free or cheap formula in Haiti and other countries is a super bad idea (add to all the reasons you stated, the fact that if powdered formula is given out, it can be hard to obtain pure water to mix it, thus leading to diareah, dehyrdation etc.) but I had no clue whatsoever about all the superstitions against breast feeding! WOW. You have an up-hill battle to work against--but it's one worth fighting. I wish I could help you in person--but I'll hold up your hands from afar with prayer for the Mom's and babies. (I am an "experienced breast feeder", having a combined total of 9 years bf'ing spread among my 3 bio children, and having bf in-spite of numerous obstacles and challenges.)

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  2. Interesting, good comparison about overweight Americans.
    It was interesting to me when I was in Haiti for the Haitian nurse who worked at the clinic to tell us some of what she though on worms.
    About nursing:
    Do you see formula companies perpetuating this?

    http://www.breastfeeding.com/advocacy/advocacy_boycott.html

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  3. Gwen, this was excellent, thank you for writing that all out. I did not know all the background beliefs and I have a much better understanding of WHY things are regarding breastfeeding. Keep writing and teaching these are important stories to hear.

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  4. I liked the very real (for us) comparison to the American diet. So true. We watched Food, Inc. last weekend and Jan and I are rethinking the way we buy and consume food and its correlate repercussions on families, health, and the environment. I see it as a an issue of faith, too. God provides what's good for us....we take it, distort it, and our distortion leads to death in so many ways.

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  5. Thank you for taking the time to explain the complexities of the breastfeeding issue in Haiti. Actually, the idea that formula is better was part of American thinking in the 50s, 60s, and 70s. Even poor Americans would buy formula (and spend precious money) rather than breastfeed (free) because 1) it was a status thing and 2) physicians and corporations encouraged it.

    I've shared your post with a RN friend of mine who is going to Haiti on a medical mission trip to an orphanage this summer. She wants to help educate the teen girls and some of the village women. Your information should be very helpful to help her understand the cultural beliefs.

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  6. I had no idea how many superstitions there were in Haiti on breastfeeding.
    I have three boys and have nursed them over 1 year each. Being in the US one would think that would be easy but I was discouraged many times by family, friends, and even doctors so I can't imagine how it would be in Haiti when basically everyone believes it is bad and there are books even telling you it is. I think you should try to publish what you wrote. The doctors and nurses coming to Haiti need to know what the Haitian people believe and also what is best for the babies. I enjoy reading your blog and read it everyday.

    Jennifer from CA

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  7. VERY interesting. Thanks for sharing!

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  8. Thank you for that insight!! Something important for us to know about the Haitian culture for sure. I love learning about these things from your perspective.

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  9. The contaminated water is also often the only option for mixing with formula - this is a huge drawback for formula feeding.

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  10. Gwenn - Thank you for this post! It was VERY informative and interesting. Being so interested in breastfeeding myself, I really appreciated what you wrote.

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  11. I imagine that it is also true in Haiti, that to stretch the supply of formula they don't mix it in the proper proportions.

    Hats off to you Gwenn for taking the time to educate yourself and others about such an important issue. I can't imagine how frustrating it is for you to witness mothers going about things 'ignorantly' and not be able to convince them otherwise.
    Thanks again for helping us understand.

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  12. Gwenn, My husband and I are from different cultures, so I completely understand the wives tales/superstitions. Even tho' he is a long-time Christian, there were so many that he never even questioned because they were an engrained belief he'd been told all his life. Thankfully they are not life threatening like the ones you shared.
    Praying that the God of All Power and Might would break superstitions in the hearts and minds of Haitians and that breastfeeding would be embraced.

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  13. This is just insane. How can I help? How can I be in direct line of change? Come to Haiti? Round up some donations? Please contact me.

    Thanks!
    Phoebe
    http://www.facebook.com/BreastfeedingMeansBusiness

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