41(2):186-190,2000

PUBLIC HEALTH

Influence of 1991-1995 War on Breast-feeding in : Questionnaire Study

Zora Zakanj, Giovana Armano1, Josip Grguriæ, Vesna Herceg-Èavrak

Children’s Hospital ; and 1Private Pediatric Office, Zagreb, Croatia

Aim. To investigate the influence of 1991-1995 war on the prevalence, duration, and practice of breast-feeding Croatian children up to 5 years of age. Method. In 1996, interviews were conducted in households with children up to 2 years of age (757 children) and 2-5 years of age (1,180 children). Data for war-free areas, war-affected areas, and areas liberated after several years of occupation were analyzed separately. Results. In 1996, 94.6% of mothers started breast-feeding, which lasted for an average of 3.4±2.9 months. The proportion of mothers who started breast-feeding did not vary with respect to either war-related or geographic areas of the country. Breast-feeding was significantly longer in war-free than in war-affected areas (3.7±3.1 vs. 2.7±2.1 months, respectively; p=0.015). The duration of breast-feeding in Croatia’s geographic regions, , Hrvatsko Primorje, and , was significantly longer than in (3.9±3.4 vs. 3.4±3.0, respec- tively; p=0.037). On the country level, 49.4% of babies were fed on demand and 43.3% according to a daily schedule. The percent of children who were not breast-fed was significantly higher (p=0.002) in the older age group (2-5 years of age, 9.3%) than in the younger age group (up to 2 years of age, 5.4%). Conclusions. The war decreased the prevalence and duration of breast-feeding, which might be related to regu- lar humanitarian donations of infant food and mother’s milk substitutes, especially in the war-affected areas. UNICEF breast-feeding campaign, which started in 1993, appeared to be effective.

Key words: breast-feeding, child nutrition; Croatia; food supply; health education; humanitarianism; infant nutrition; milk, human; war

Even before the 1991-1995 war (1), the number Following United Nations Children’s Fund of breast-fed babies in Croatia was very low (2). (UNICEF) suggestions, many countries in the Over the past twenty years, breast-feeding was more world have started a campaign to promote common in the rural than in the urban population, breast-feeding (11-15). Breast-feeding promotion but more recent research showed that the rate of program has been received best in regions with a breast-feeding in both groups has leveled out (3). better social and economic status (4,5). UNICEF This means that nowadays only about 75% of moth- and the World Health Organization (WHO) have ers breast-feed their babies when they leave the ma- defined their own strategy to promote breast-feed- ternity hospital, and no more than 30% continue to ing as “Ten Steps to Successful Breast-feeding” do so up to the end of baby’s third month of life (4). (15). The breast-feeding promotion strategy in- With the development of the baby food indus- cludes all levels of society (16), individuals as well try in the last decades, especially mother’s milk as communities, but aims primarily at maternity substitutes, a decrease in the number of breast-fed hospitals, where mothers make the first contact babies has been noticed throughout the world with their babies. The success and length of (4,5). Subtle advertising and sales methods used breast-feeding depends on the quality of this en- for mother’s milk substitutes (6-9) have sup- counter (17). Maternity wards that successfully pressed breast-feeding, which is the best form of apply the strategy for the promotion of breast-feed- infant nutrition. This has resulted in a small rise in ing, as assessed by a national assessment team, re- the infant morbidity rate from various diseases, ceive the “Baby-Friendly Hospital” title (15,18). which caused great concern to the pediatricians During the breast-feeding promotion campaign in (10). Croatia (1993-1998), 15 of the total of 32 maternity

186 www.vms.hr/cmj Zakanj et al: Influence of War on Breast-feeding in Croatia Croat Med J 2000;41:186-190 wards received this title, and all others made sig- emphasizing the advantages of mother’s milk nificant improvement (19). (22-24), but in reality poorly keeping up to the rec- UNICEF came to Croatia in 1991, and started ommendations. The Innocenti Declaration, which the breast-feeding promotion campaign in 1993 regulates the manner of sale, advertisement, and (10). The aims of the campaign were education of distribution of mother’s milk substitutes, also ap- health workers in primary health care and mater- plies to all humanitarian baby food donations nity wards, preparation of educational literature, (25), but the decrease of breast-feeding in war-af- and drawing public attention to the issue of fected areas of Croatia, as documented in this breast-feeding. A special place in the campaign study, opens the possibility that adverse influ- was given to the “Baby-Friendly Hospital” initia- ences have been stronger. tive, because the recommendations defined in the The aims of our study were to determine the “Ten Steps to Successful Breast-feeding” had not prevalence and duration of breast-feeding chil- been observed in Croatian maternity wards. The dren up to 2 years of age in areas differently af- babies were separated from their mothers (except fected by the 1991-1995 war in the country (1); to in some small hospitals), breast-feeding on de- determine the prevalence of breast-feeding on de- mand was not practiced, and milk formulas were mand and on schedule; and to assess whether the used widely. However, it is also possible that a breast-feeding campaign, initiated by UNICEF in subtle reason for taking babies off mother’s milk 1993, had noticeable effects three years later. during the war in Croatia could be war-related hu- manitarian aid, which regularly included sup- Subjects and Methods plies of milk formulas, bottles, and teats (20-24). During 1996, the Children Hospital Zagreb and UNICEF Humanitarian organizations have defined regula- Office for Croatia conducted a specially structured epidemio- tions and methods for the distribution of milk for- logical study of parental knowledge and behavior concerning mulas and for mother’s milk substitutes, always children’s health and nutrition in the Republic of Croatia. Sample Selection Bearing in mind the differences in the density of popu- lation and in the intensity of war activities in different regions of the country, a specific method was used to select samples. In this way we ensured the research to be as representative as Northern Croatia possible and the stratification procedures applied properly. The target population was defined as “households with ZAGREB children under the age of 5”. A household was operationally

KARLOVAC defined as a group of persons who live and eat together. A Slavonia OSIJEK RIJEKA stratified random sample of clusters was used. A “cluster” PAZIN Gorski Kotar PAKRAC VUKOVAR VINKOVCI SLAVONSKI BROD was a randomly selected population group of 40 households Istria with children under the age of 5. The cluster sampling was a Banovina two-stage process. Firstly, we divided the Republic of Croatia into three areas (strata) depending on the intensity of war ac- GOSPIÆ tivities (Fig. 1): (a) war-free areas, which were not signifi- Hrvatsko cantly affected by the war activities or were liberated before UNPA EAST Primorje 1995 – these included the city of Zagreb, Northern Croatia, ZADAR UNPA WEST KNIN UNPA NORTH Istria, Hrvatsko Primorje, and Gorski Kotar; (b) war-affected UNPA SOUTH areas, in which the most intensive war activities occurred be-

ŠIBENIK fore 1995, but after the fighting remained under the control of Croatian Government; and (c) “liberated areas” – areas occu- SPLIT pied in 1991 and reintegrated into the Republic of Croatia during the 1995 “Lightning” and “Storm” military campaigns (1). In 1996, the eastern part of the country (UNPA East, Fig. 1) was still occupied and thus was not included in this study. The traditional division of the Republic of Croatia into DUBROVNIK six regions (Northern Croatia; Slavonia; Lika and Banovina; Istria, Hrvatsko Primorje and Gorski Kotar; Dalmatia; Fig. 1) was also used in the analysis of data. The second step in the sample definition was identifica- Figure 1. Map of Croatia. Yugoslav Federal Army and tion of households to conduct the interview. The Republic of Serbian paramilitary forces have occupied the four Croatia was first divided into 7,832 segments of 120-150 zones (United Nations Protected Areas, UNPA South, households. Among them, 370 segments were selected by North, East, and West) in 1991 after heavy fighting. In probability proportional to size (size was defined as number 1995, Croatian Police and Army liberated zones West of households per segment). Then, the households were sys- (May), South and North (August), whereas UNPA East tematically selected, so that a cluster of 40 households from each segment was included in the sample. This resulted in was peacefully reintegrated in January 1998. In this text 14,800 households selected for the final stage. Among them, these areas are designated “liberated”. Areas neighbor- 1,563 (10.6%) were those with children under 5 (a total of ing the 4 UNPA zones, and parts of Dalmatia around cit- 1,937 children). ies of Dubrovnik, Zadar and Šibenik, which after Survey 1991-1992 fighting remained under control of Croatian Government, are considered war-affected zones. The re- The fieldwork was done by a professional agency maining parts of the country have not been directly af- (PULS, Zagreb) and 87 field workers were engaged. They were all university students from different parts of Croatia. fected by war, and are designated as war-free. Croatian Before the survey, they all attended a training course on their provinces with their historic and officially used names future work, and with the questionnaire received extensive are also indicated.

187 Zakanj et al: Influence of War on Breast-feeding in Croatia Croat Med J 2000;41:186-190 instructions on its filling. The respondents were mothers or duration of breast-feeding was recorded in Istria, caretakers. Hrvatsko Primorje, and Gorski Kotar (3.9±3.4 Data related to breast-feeding, duration of breast-feed- ing, type of child nutrition, as well as feeding on demand or months), compared to 3.4±3.0 months in Slavonia according to a schedule, were taken from the questionnaire. (p=0.037) (Table 2). On the basis of those answers, the sample was divided into two groups of children: up to 2 years of age, and those be- Prevalence of Breast-feeding on Demand or tween 2 and 5 years of age. There were 757 children up to 2 a Schedule years of age, 357 (47.2%) boys and 400 (52.8%) girls. The group of children between 2 and 5 years of age comprised The UNICEF breast-feeding promotion strat- 1,180 children, 620 (52.5%) boys and 560 (47.5%) girls. egy “Ten Steps to Successful Breast-feeding” rec- Statistical Analysis ommends that babies should be fed on demand Population indicators for the war-related and geograph- and not according to a schedule (15,26). As shown ical , as well as for Croatia as a whole, were in Figure 2, 49.4% of the babies were fed when calculated. Differences among the proportions were tested by the c ²-test, whereas the analysis of variance (ANOVA) was they demonstrated hunger and 43.3% according to used to test the differences between the means. When a daily schedule (the mothers of remaining 8.3% ANOVA showed significant difference, Duncan post-hoc test answered “don’t know” or “equally”). These two was used. The differences with p<0.05 were considered sta- tistically significant. practices were not equally distributed in different areas (p=0.001, c ²-test), with as many as 66.2% Results babies fed on demand in Zagreb, compared to only 33.7% in Dalmatia. Prevalence of Breast-fed Children up to 2 Years of Age Assessment of the UNICEF’s Breast-feeding Almost 95% of the children up to two years of Promotion Campaign age were started being breast-fed, i.e., they were The effects of the breast-feeding promotion breast-fed for at least a day (Table 1). War-free ar- campaign introduced by UNICEF in 1993, were in- eas of Croatia had the highest breast-feeding rate directly assessed by comparing the breast-feeding (95.9%), whereas in the war-affected (91.7%) and rate in children up to 2 years of age with that in liberated (91.2%) areas that rate was lower. children 2-5 years of age in 1996. The younger age Among the war-free regions, the city of Zagreb group was born when the campaign was in full im- had the highest (96.6%) and Lika and Banovina plementation in Croatia, whereas the older age the lowest (91.6%) rate. However, neither of these group was born at the beginning or shortly after differences were statistically significant. the introduction of the breast-feeding promotion program. In the older age group, 9.3% of the chil- Duration of Breast-feeding of Children up to dren have never started being breast-fed, com- 2 Years of Age pared to 5.4% in the younger age group (p=0.002, The average length of breast-feeding in the c ²-test) (Table 3). whole country was 3.4± 2.9 months (Table 2), the longest in the war-free areas (3.7±3.1 months) and almost a month shorter in the war-affected areas (2.7±2.1 months, p=0.015) (Table 2). The longest Table 2. Average duration (months, mean±SD) of breast-feeding children under the age of 2 in Croatia in 1996a Average length of Table 1. Prevalence of breast-fed children under the age Area of 2 in Croatia in 1996a breast-feeding % Mothers practicing Croatia, N=571 3.4± 2.9 Area 95% CIb breast-feeding War-free, n=408 3.7± 3.1b Croatia 94.6 92.9-96.3 War-affected, n=107 2.7± 2.1b War-free 95.9 94.1-97.6 Liberated areas, n=56 3.1± 2.7 War-affected 91.7 87.0-96.4 Zagreb, n=115 3.7± 2.8 Liberated 91.2 84.6-97.7 Northern Croatia, n=114 3.7± 2.9 Zagreb 96.6 93.7-99.6 Lika, Banovina, n=66 2.8± 2.5 Northern Croatia 95.2 91.7-98.8 Slavonia, n=143 3.4± 3.0c Lika, Banovina 91.6 85.7-97.4 c Slavonia 94.0 90.4-97.5 Istria, Hrvatsko Primorje, 3.9± 3.4 Gorski Kotar, n=36 Istria, Hrvatsko 96.2 90.8-100.0 Primorje, Gorski Dalmatia, n=97 3.6± 3.3 Kotar aChildren still on breast-feeding were excluded. Dalmatia 93.9 89.7-98.1 bStatistically significant difference between war-affected areas and war-free areas (p=0.015 by ANOVA and Duncan test for mul- aBreast-feeding was defined as at least one day on breast-feeding, tiple comparisons). i.e., a start of breast-feeding. cStatistically significant difference between Istria, Hrvatsko bCI – confidence interval. There were no statistically significant Primorje, and Gorski Kotar on one side, and Slavonia on the other differences between the groups (p=0.051, c 2-test). (p=0.037 by ANOVA and Duncan test for multiple comparisons).

188 Zakanj et al: Influence of War on Breast-feeding in Croatia Croat Med J 2000;41:186-190

Northern Croatia

Lika, Banovina

Slavonia

Istria, Hrvatsko Primorje, Gorski Kotar

Dalmatia

Zagreb

0 10203040506070 Percent Figure 2. Percent of breast-feeding in children aged 0 to 2 years on demand (open bars) and according to a daily sched- ule (closed bars) in different regions of Croatia in 1996. There was statistically significant difference in types of breast-feeding among the regions of Croatia (p=0.001, c 2-test).

unfavorable circumstances, and emphasized the Table 3. Comparison of the number of breast-fed and fact that it brings emotional contact and that non-breast-fed children in two age groups in Croatia in 1996 mother’s milk is sterile, has optimal temperature, immunological advantages, and other benefits No. (%) of children of age (16,20-24). In order to avoid the incorrect and un- Breast-feda controlled distribution of milk formula in war up to 2 years 2-5 years time, the Commission for the Coordination of Aid No 41 (5.2) 109 (9.3) and Child Health Care in Special Circumstances Yes 715 (94.6) 1,060 (90.7) drew up guidelines for the distribution of baby aBreast-feeding was defined as at least one day on breast-feeding, food, and issued recommendations that it should i.e., a start of breast-feeding. be exclusively distributed through the health ser- bStatistically significant difference between two age groups vices (19). However, it appears that this was not 2 (p=0.002, c -test). enough and that the distribution of milk formulas was too liberal. Discussion In the war-free areas of the country, the best results in terms of the length of breast-feeding Our study revealed that babies in the war-free were seen in Istria, Hrvatsko Primorje, and Gorski areas of Croatia were breast-fed significantly more Kotar. This was the consequence of a long-term often and longer than the babies in the war-af- promotion of healthy way of life in those areas. fected areas. This is opposite to the expectation The region of Istria, and particularly the city of that mothers in war-affected areas would rely Rijeka, was one of the first regions in Croatia to more on natural, i.e., war-independent, type of systematically apply the breast-feeding promotion feeding for their children. Although this study did program, and the Rijeka’s maternity ward was the not investigate direct causes of the decreased rate first in Croatia to get the title of “Baby-Friendly of breast-feeding in specific places, we believe that Hospital” (27). the understandable decrease in preventive activi- According to the regulations in “Ten Steps to ties, a fall in the level of health educational mea- sures, and especially uncontrolled humanitarian Successful Breast-feeding”, babies should be fed donations were the main factors that caused the on demand and not according to a schedule (15). decrease in the prevalence of breast-feeding in the Mothers from Zagreb had the highest rate of bre- war-affected areas. ast-feeding on demand, probably because of a sup- porting atmosphere and widespread educational During the war in Croatia, large donations in program which promoted breast-feeding. the form of food were delivered on regular basis, and these included various milk formulas. Organi- The success of the breast-feeding promotion zations which work to encourage breast-feeding programs was indirectly confirmed by the in- (IBFAN – International Baby Food Association Net- creased rate of breast-fed children in the younger work, IFEG – Infant Feeding in Emergencies Group, age group, whose parents have been longer influ- UNICEF,WHO, Red Cross) and other humanitarian enced by breast-feeding promotion education, in organizations, which delivered baby foods, de- comparison to children who were born at the be- fined regulations for the delivery and correct use ginning or shortly after the introduction of the of milk formulas in extraordinary circumstances. breast-feeding promotion program. Actually, this They all pointed out the advantages of breast-feed- is the first and only indicator of the effectiveness of ing for both the baby and the mother, especially in the breast-feeding promotion campaign in Croatia.

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